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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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