BADMINTON Special Olympics Sports Skills Program
BADMINTON Special Olympics Sports Skills Program
BADMINTON Special Olympics Sports Skills Program
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Application for Participation in <strong>Special</strong> <strong>Olympics</strong><br />
Athlete ID or SS # ____________________________ Male _____________ Female _____________<br />
Date of Birth ___/___/___ Height _________ Weight ____________<br />
Athlete Information<br />
Name of Athlete __________________________________________________________________________<br />
Address ________________________________________________________________________________<br />
Phone Number ___________________________________________________________________________<br />
Name of Parent or Guardian ________________________________________________________________<br />
Address (if different) ______________________________________________________________________<br />
Phone Number (if different) ________________________________________________________________<br />
Emergency Information<br />
Person to Contact in Case of Emergency ______________________________________________________<br />
Address ________________________________________________________________________________<br />
Phone Number ___________________________________________________________________________<br />
Health and Accident Insurance Information<br />
Company Name _____________________ Policy Number _______________________________________<br />
Health Information<br />
Circle One: Comments:<br />
Down syndrome Yes No<br />
Atlanto-axial Instability Evaluation by X-ray<br />
(Circle Yes for positive, Circle R for negative) Yes R<br />
History of:<br />
Diabetes Yes No<br />
Heart Problems/Blood Pressure Elevation Yes No<br />
Seizures Yes No<br />
Vision Problems and/or<br />
Less than 20/20 Vision in One or Both Eyes Yes No<br />
Hearing Aid/Hearing Problems Yes No<br />
Motor Impairment Requiring <strong>Special</strong> Equipment Yes No<br />
Bleeding Problem Yes No<br />
Head Injury/History of Concussion Yes No<br />
Fainting Spells Yes No<br />
Heat Illness or Cold Injury Yes No<br />
Hernia or Absence of One Testicle Yes No<br />
Recent Contagious Disease or Hepatitis Yes No<br />
Kidney Problems or Loss of Function in One Kidney Yes No<br />
Pregnancy Yes No<br />
Bone or Joint Problems Yes No<br />
Contact Lenses/Glasses Yes No<br />
Dentures/False Teeth Yes No<br />
Emotional Problems Yes No<br />
<strong>Special</strong> Diet Needs Yes No<br />
Other Yes No<br />
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