Kentucky Athlete Medical - Release Form
Download the document to the computer for easy use
There are more pages to preview,Read on

ATHLETE MEDICAL – RELEASE FORM
For questions please call: (502)695-8222 / (800)633-7403

PLEASE FILL OUT COMPLETELY
ATHLETE INFORMATION
Middle Name:
Last/Family Name:
Suffix: (Jr., III, etc.)
State:
Zip:
County:
Birthdate (mm/dd/yy):
/
/
Wheelchair Athlete:
Cell Phone:
Work Phone:

First/Given Name:
Address:
City:
Gender:
Male
Female
Home Phone:
E-mail Address:
Name of Parent of Guardian:
Phone: (
Address:
City/State/Zip:
Has this individual participated in Special Olympics within the past 5 years?
Yes
EMERGENCY INFORMATION
Emergency Contact:
Emergency Phone:
HEALTH AND ACCIDENT INSURANCE INFORMATION
Company Name:
Policy #:

Yes

No

)
No

FOR DOWN SYNDROME ATHLETES ONLY: ATLANTO-AXIAL INSTABILITY ASSESSMENT FOR ATHLETES WITH DOWN SYNDROME
EXAMINER’S NOTE: If the athlete has Down Syndrome, Special Olympics requires a full radiological examination establishing the absence of Atlanto-axial Instability
before he/she may participate in sports or events which, by their nature, may result in