St. Mark's School Young Athletes Program - Special Olympics Massachusetts

Select Which Session You Would Like To Attend

Name*

First Last

Gender*

Male
Female

Date of Birth*

Address*

Street Address Address Line 2 City State ZIP Code

Basic Health Information

How Did You Hear About Us

Is there anything about your child that you think we should know before he/she participates? Please include any known allergies.

Please let us know which school your son or daughter may attend in the area. We are starting to work with different Pre-K and Elementary schools to offer new programming!

T-shirt Size

If your child is NEW to the program please provide a shirt size. This shirt is your child's uniform and he/she should wear it each week.

Participant is being registered as a:*

Traditional Athlete (diagnosed w/ intellectual disability)
Unified Partner (not diagnosed w/ intellectual disability)

Parent/Guardian Name*

Phone*

Email*

Release Form

I am the parent/guardian of the minor participant, on whose behalf I have submitted the attached application for participation in Special Olympics. I further represent and warrant that to the best of my knowledge and belief, the participant is physically and mentally able to participate in Special Olympics. In permitting the participant to participate, I am specifically granting my permission, forever, to Special Olympics to use the participant’s likeness, name, voice and words in television, radio, film, newspapers, magazines and other media, internet and in any form, for the purpose of publicizing, promoting or communicating the purposes and activities of Special Olympics and/or applying for funds to support those purposes and activities. I also understand that group data collected from the Young Athletes Pilot Program will be used to plan, evaluate, and improve the program. If a medical emergency should arise during the participant’s participation in any Special Olympics activities, at a time when I am not personally present so as to be consulted regarding the participant’s care, I hereby authorize Special Olympics, on my behalf, to take whatever measures are necessary to ensure that the participant is provided with any emergency medical treatment, including hospitalization, which Special Olympics deems advisable in order to protect the participant’s health and well-being. (IF YOU HAVE RELIGIOUS OBJECTIONS TO RECEIVING SUCH MEDICAL TREATMENT, PLEASE CONTACT SPECIAL OLYMPICS MASSACHUSSETTS) I am the parent (guardian) of the participant named in this application. I have read and fully understand the provisions of the above release, and have explained these provisions to the participant. Through my signature on this release form, I am agreeing to the above provisions on my own behalf and on the behalf of the participant named above. I hereby give my permission for the participant named above to participate in Special Olympics games, recreation programs, and physical activity programs.

Signature*

Signature Printed Name*

Signature Date*

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St. Mark’s School Young Athletes Program

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St. Marks School Young Athletes Program

Release Form