Athlete & Unified Partner Release Form(Please print in ink using block letters or type)
Release to be completed by allathlete or unified partner(over 18 years of age)
I, ______, of ______(Special Olympics GB clubname) am at least 18 years old and have submitted the attached application for membership of and participation inSpecial Olympics including sports training and competition, social events and Healthy Athletes Programme.
I confirm to the best of my knowledge and belief, I am physically and mentally able to participate in Special Olympicsactivities. I have undertaken a medical examination including checks on symptoms of adverse neurological effects,including those that could result from spinal cord compression or symptomatic AAI with a licensed physician who hascertified, based on an independent medical examination, that there is no medical evidence which would preclude orrender inadvisable, my participation in Special Olympics.
I also understand that Special Olympics recommends that I have regular health screenings conducted by a licensedphysician.
Special Olympics has my permission to use my likeness, name, voice, or words in either television, radio, film,newspapers, magazines, and other media, and in any form, for the purpose of advertising, or communicating thepurposes and activities of Special Olympics and/or applying for funds to support those purposes and activities.
Participation in the Special Olympics Healthy Athletes Programme is optional. Data collected by the Healthy AthletesProgramme may be used (with identifying personal details removed) for research purposes.
If, during my participation in Special Olympics activities, I should need emergency medical treatment, and I am not able togive my consent or make my own arrangements for that treatment because of my injuries, I authorise Special Olympics totake whatever measures are necessary to protect my health and well-being, including, if necessary, hospitalisation.
I, the athlete named above, have read this paper and fully understand the provisions of the release that I am signing. Iunderstand that by signing this paper, I am saying that I agree to the provisions of this release.
Signature of Athlete or Unified Partner______Date ______
Release to be completed byparent/guardian of a minor athlete/unified partner(under the age of 18 years of age)
I am the parent/guardian of the athlete named in this application. I have read and fully understand the provisions of the aboverelease, and have explained these provisions to the athlete. I agree to the above provisions on my own behalf and on behalfof the athlete name below.
I am the parent/guardian of______, of ______(Special Olympics GB clubname) a minor on whose behalf I have submitted the attached application for participation in Special Olympics.
I hereby represent that the athlete has my permission to participate in Special Olympics activities including sports trainingand competition, social events and Healthy Athletes Programme.
I further represent and warrant that there is no medical evidence which would preclude the athlete from participating inSpecial Olympics following a full medical check by a Licensed Medical Professional for symptoms of adverse neurologicaleffects including those that could result from spinal cord compression or symptomatic AAI and I also understand thatSpecial Olympics recommends that the athlete has regular health screenings conducted by a licensed physician.
In permitting the athlete to participate, I am specifically granting my permission to Special Olympics to use the athlete'slikeness, name, voice and words in television, radio, film, newspapers, magazines and other media, and in any form, forthe purpose of advertising or communicating the purposes and activities of Special Olympics and/or applying for funds tosupport those purposes and activities.
Participation in the Special Olympics Healthy Athletes Programme is optional. Data collected by the Healthy AthletesProgramme may be used (with identifying personal details removed) for research purposes.
If a medical emergency should arise during the athlete's participation in Special Olympics activities, at a time when I amnot personally present so as to be consulted regarding the athlete's care, I hereby authorise Special Olympics, on mybehalf, to take whatever measures are necessary to ensure that the athlete is provided with any emergency medicaltreatment, including hospitalisation, which Special Olympics deems advisable in order to protect the athlete's health andwell-being.
Signature of Parent/Guardian______Date ______
Page 1 of 2Athlete & Unified Partner Release Form041215