Applicant information

First name

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Last name

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Phone

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Phone type
Email address

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Email type

Address

Address

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Apartment, suite, etc. (optional)
City

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Country/region

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State

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ZIP code

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Date of birth

Month

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Day

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Year

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Background

Gender

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Ethnicity

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Languages
A.

Applicant Additional Information

Living arrangement

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What team/local program do you participate with?

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B.

Parent/Guardian/Caregiver Information/Emergency Contact - Required

First name

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Last name

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Phone number

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Street address

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City

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State

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Zip code

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Email address

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What is your relationship to the Athlete?

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Are you interested in becoming a Volunteer for Special Olympics RI?

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C.

Associated Conditions (Required)

Select all that apply

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If Other was chosen, please specify:

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D.

Assisted Devices and Accommodations (Required)

Mobility

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Lifestyle aids

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Communications Support

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Medical Devices

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Personal Support Needed

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1:1 Support: Additional detail:

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Dietary Restrictions

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Other Dietary Restriction detail:

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E.

Shirt Size

Athlete's Shirt Size

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Other Shirt Size detail:

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F.

General Health Questions

Height (ft)

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Weight (lbs)

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Do you have a heart condition?

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Do you have high blood pressure?

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Do you have asthma?

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Do you have diabetes that requires you to take insulin?

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Do you have a vision impairment?

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Do you have a hearing impairment?

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Do you have a bleeding disorder?

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Has a doctor ever limited your participation in sports?

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Do you have epilepsy or any type of seizure disorder?

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Do you have sickle cell disease?

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Have you ever had a concussion?

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If you answered Yes to the previous question, how many concussions have you had in your lifetime, and what was the date of your last concussion?

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Do you have behavior, mental health, and/or sensory conditions?

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If you answered Yes to the previous question, please specify:

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Do you have severe allergies that require the use of an EpiPen?

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If you answered Yes to the previous question, please specify:

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If you selected Medication/Drugs, please specify:

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If you selected Other in the previous question, please specify:

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G.

Medication and Treatment (Required)

Are you taking any prescription or over-the-counter medications or treatments? (Including birth control pills, insulin, multivitamins, allergy spots or pills, EpiPen, asthma inhalers, epilepsy medication, anti-inflammatory medication, supplements of any kind, etc.)

List all medications, their dosages, and how frequently it is needed:

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H.

Form Completion

Name of person completing this form

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Today's date

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Is this form being completed by someone other than the athletes?

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If you answered Yes to the previous question, please select the relationship to the athlete:

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Confirmation

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