New York Medical Release Form For Participation in Special OlympicsNew York Medical Release Form For Participation in Special Olympics
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MEDICAL & CONSENT RELEASE

For Participation in Special Olympics
Special Athlete
Special Partner

REGION: ____________________________________________

PART 1:

(ATHLETE INFORMATION)

Training Club Name: ___________________________________________________
Male
Female Date of Birth (month/day/year)___________________
Athlete’s Name:_____________________________________________________________________________________________________________________________________
Athlete’s Address:___________________________City:__________________State: ______Zip:____________ Athlete Home Phone #:_____________________________
Parent/Guardian:_________________________________________________________________________________ Parent Primary Phone #:___________________________
Social Security #: ______________________________________________________________________________ Parent Secondary #:_______________________________
Emergency Contact (if other than parent/guardian):____________________________________