Program Application 2016-2017
Please complete this Program Application to participate in Special Olympics Programs and Competitions.
This application is for Traditional Delegations, Unified Delegations and School Based programs.
Part 1: Program information
Program / School Name: ______School District ______
Program / School Address: ______City:______Zip: ______
School enrollment #: ______
Program / School contact name: ______
Phone/ Cell: ______Fax: ______
Email: ______
Additional program/ School contacts:
Coach: ______Email: ______
Athletic Director: ______Email: ______
Teacher/Para:______Email: ______
Student Leader: ______Email: ______
Program Level: Mark one (if registering as a district please complete separate form for each school)
Preschool Elementary School Middle School High School College Community Program
Program Model Offered: Traditional Unified
Consent to participate:
· I certify the information provided on this registration form is correct
· I will contact Special Olympics Arizona whenever program information changes or updates need to be made
· I understand all Athletes participating in Special Olympics must pass a sport physical. Partners under the age of 18 must complete a Unified Partner Form (SOAZ form). All other Partners must complete volunteer requirements.
· Each school based program will receive 2 participation update surveys per year (1 fall, 1 summer). Please be prepared to answer the questionnaire by designated dates for reporting purposes
Program / School contact signature:
______
SOAZ Staff Contact:
SOAZ internal use only:
Champion School Partner School
Youth Leadership Unified Sports Whole School Engagement
Program / School Name: ______
Part 2: Program Participation
Mark each sport/ program your delegation plans to participate in or would like information on:
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Program Application 2016-2017
Aquatics
Softball
Bocce
Golf
Bowling
Soccer
Floorball
Alpine Skiing
Snowboarding
Snowshoeing
Cross Country Skiing
Speed Skating
Figure Skating
Basketball
Cheerleading
Flag Football
Athletics
Kayaking
Volleyball
Powerlifting
Tennis
Equestrian
Young Athletes
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Program Application 2016-2017
I would like to receive information on area events.
Mark each program activity your delegation plans to participate in:
· Youth Leadership- Unified Clubs Other/please explain: ______
· Unified Activities – Spread the Word to End the Word Campaign Minutes that Matter
Fan in the Stands Community based events Sports Expo / Field Day Healthy LEAP (Health Education)
Other: ______
School Based delegations only:
Unified Sports Adaptive PE Curriculum Unified Sports through Arizona Interscholastic Association (AIA)
Unified Activity (dance/ School Assembly) Other: ______
Please provide a brief description of fun activities or other creative ideas you might have during the year:
If possible please follow up with a planned date and location of events or a summary of the activity. Include pictures and any media links which highlighted the activity.
School Based delegations only:
Unified Strategies for Schools Department of Education funding request: Examples – Transportation for Special Olympics events, Equipment, Uniforms, Teacher funded project, Student funded Project
If you are a school based delegation please contact your Area Director for levels of support.
River Area Director, Lisa Ball
Mountain & Monument Area Director, Jamie Heckerman
Palo Verde Area Director, Jamie Heckerman
Four Peaks Area Director, Jamie Heckerman
Coronado Area Director, Holly Thompson
Support Services Office, Isaac Sanft
Program / School Name: ______
Please check each item below to verify your acceptance
This program will follow, to the best of its ability, the rules and regulations of Special Olympics Inc. and Special Olympics Arizona, including but not limited to:
/ Enrollment of all Athletes and Partners (a current Athlete/Partner Medical Release & Consent Form on file with Head of Delegation and SOAZ state office for each Athlete/Partner.) / All coaches for this Delegation will have copies of each Athlete/Partners' Medical Release & Consent Form in their possession at all practices, competitions and other events.
/ I have reviewed the SOAZ Volunteer Application, Screening and Training Policy and the SOAZ Coaches' Certification Policy.
/ All coaches for this Delegation have met (or will meet before holding their first practice) the certification requirements outlined in the current SOAZ Volunteer Application, Screening and Training Policy and the SOAZ Coaches' Certification Policy.
/ Registration of all volunteers (current volunteer application forms on file/approved).
/ I have reviewed Article 1 of the Special Olympics International Official General Rules.
/ Oversight of Special Olympics Code of Conduct for all volunteers, Athletes, Partners and parents.
/ Adherence to all SOAZ fundraising policies/procedures with respect to all funds raised in the name of Special Olympics Arizona.
/ I have reviewed and will adhere to all SOAZ accounting procedures with respect to funds raised and spent in the name of Special Olympics, cash advances, reimbursement requests, Purchase Orders, etc.
/ Acting as a communication liaison between the area/state office and program coaches, parents, Athletes and volunteers.
/ Refraining from entering into any written agreement (contracts) without approval from Area/SOAZ offices.
/ Refraining from opening any school or bank accounts for this Delegation.
/ Attendance at all required meetings, trainings, opening ceremonies and conferences.
Failure to Comply
Please check each item below to verify your acceptance:
/ This local program understands that failure to follow these agreements may result in immediate suspension of rights to conduct the Special Olympics program. / Under these conditions, I request accreditation as a local program under the supervision of Special Olympics Arizona.
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