General Information |
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| First Name: |
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| Last Name:: |
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| Gender: |
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| Address |
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| City/Town (*) |
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| Province: (*) |
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| Postal Code (*) |
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| Home Phone: (*) |
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| Work Phone |
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| Fax Number: |
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| E-Mail: |
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| Birthdate (DD-MMM-YYYY); (*) |
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| Aboriginal Heritage:(Information used for indigenous games) |
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| Health Card Number: |
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Athlete Medical Information |
| Family Physician |
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| Phone |
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| Other Medical Insurance(In case of emergency please notify): |
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| Insurance Number |
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| Name: |
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| Home Phone |
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| Work Phone (Alternate Contact): |
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| Cell Phone |
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| Name/Relationship: |
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| Home Phone |
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| Cell/Work Phone: |
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| Special Dietary Concerns: |
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| Please Explain: |
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Atlantoaxial Instibility Profile |
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| Does this athlete have Down Syndrome? |
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If the athlete have down syndrome.he/she must be tested for Atlantoaxial Instability at initial registration. The result, along with the physian's signature, must be included with the orignal registration form before the athlete may be permitted to participate in training. |
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| Date of X-ray testing for Atlantoaxial Instability: |
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| Result of X_ray: |
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If the athlete has Down Synrome and has tested positive for Atlantoaxial Instability, the ahtlete cannot participate in soccer, High_Jump, Pentatthlon,Swimming(Note:only the butterfly stroke and/or diving starts are prohabited.),
Gymnastics, Alpine skiing, Floor Hockey, or Equestrian without a copy of the X-Ray result accompanied by a letter from a licensed medical professional stating that the associated risks have been explained to the athlete and parent/gardian/caregiver. as well as, a letter from tje athlete's parents or caregivers the acknowledge and accept the associated risks (Special Olympics Saskatchewan policy Manual).
*records will be stored at the Provincial office |
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Medical History Please indicate if the athlete has any of following conditions |
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| If Seizures, Controlled: |
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Any other conditions or information that you feel a coach or ambulance attendant needs to know. Please ensure
the coach is aware of any medications that the athlete is on and what medical condition it is treating.
Other(allergies, medications, behavioural concerns): |
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Athlete Waiver |
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PRIVACY POLICY
Special Olympics Saskatchewan (SOS) will protect your personal information and adhere to all legislative requirements with respect to
privacy. We use your personal information to provide services and to keep you informed and up to date on the activities of SOS,
including programs, services, special events, funding requirements and media. I, the undersigned athlete, parent and/or legal guardian
of the above named athlete, warrant you that the athlete is eligible to participate with SOS. On behalf of the athlete and myself, I
acknowledge that facilities used for SOS programs will be done so at the user’s own risk and I, hereby release, discharge and indemnify
SOS/Special Olympics Canada (SOC) from all liability for injury to person or damage to property of myself and entrant. In permitting
the athlete to participate, I am specifically granting permission to you to use the likeliness, voice and words from the athlete in
television, radio, films, newspaper, magazine, and other media, and in any form not heretofore described, for the purpose of advertising
or communicating the purposes and activities of SOS/SOC, and in appealing for funds to support such activities. I authorize SOS to act
in the best interest on behalf of the athlete to ensure that necessary care and treatment is provided in case of an emergency. All of the
above information I have given in support of this registration is true and accurate to the best of my knowledge. I understand that any
and all references to SOS/SOC include and apply equally to SOS accredited zones/communities, as well as to the Provincial and
Territorial Chapters of SOC.
OATH OF CONFIDENTIALITY
As a registered member of Special Olympics Saskatchewan (SOS), I hereby consent that I will not disclose any personal information
that I may have access to other than for the purposes of conducting the business of SOS/Special Olympics Canada. |
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Signature_________________________ Date_________________________
Signature of Witness______________________ Date_________________________ |
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