State Winter Games Permission Slip and Registration

Athlete Given Name *

First

Last

Athlete Birthdate *

#1 Parent/Guardian Name *

First

Last

#1 Athlete Parent/Guardian Email Address *

#1 Parent/Guardian Phone Number *

Emergency Contact *

First

Last

Emergency Contact Phone Number *

Medical Information

Does your athlete take medication? If so, please list each medication, dosage and frequency: If none - indicate - None *

Does athlete have allergies? If so - please list to what and what happens when exposed: If none - indicate - None: *

Does your athlete have any special medical needs? If so - please explain: If none, indicate None: *

Is there anything KCSO needs to know for an overnight stay with our group? Any triggers for unexpected behaviors and suggestions on coping mechanisms? If none - indicate None: *

Does Athlete have seizures: *

If yes- please indicate date of last seizure, if there are any triggers/auras prior to onset:

If yes to seizure's, please indicate emergent first aid needed when a seizure occurs - or do you have a seizure action plan:

Parent/Guardian Attendance

Multiple Choice

I will attend State Games
Can help at Base Camp/Party
I will not be attending Winter Games

Acknowledgements:

Permission for Athlete To Attend Summer Games with KCSO

I, as the Parent/Guardian give my expressed, written consent to any and all Coaches and volunteers of KCSO Family and Friends to take my child (athlete's name above) to Special Olympics State Winter Games, held Friday, February 10-13, 2026 at the Chestnut Ski Resort in Galena, IL. The undersigned acknowledges voluntary assumption of the risk of injury, damage or loss, both known and unknown, involved with participating in this trip including transportation to and from the activity, and I/we am/are prepared to solely assume all associated with participation in this trip. Therefore, in consideration of the permission extended to my child (athlete's name above) to participate in this trips (I/we) and (my/our) agents, representatives, assigns, heirs, and successors, hereby release, hold harmless and indemnify the KCSO Family & Friends, it’s agents representatives, officers, assigns, and successors from any and all claims, demands, actions, or causes of action, whether developed or undeveloped, known or unknown, past, present, or future, including, but now limited to, any or all damages, costs, personal injuries, including death, disabilities, direct or indirect medical expenses, pain and suffering, and attorney’s fees arising out of or in any way connected with participation in this trip.

Name *

First

Last

Payment:

State Winter Games Fee Payment *

State Winter Games Fee - $45.00
Pay by Check/Cash at 1st State Games Practice - $0.00
Scholarship - $0.00

Total

$0.00

Enter Credit Card *

Card

Name on Card

EmailPymnt *

Email of Credit Card Holder

State Winter Games Permission Slip and Registration

Medical Information

Parent/Guardian Attendance

Acknowledgements:

Permission for Athlete To Attend Summer Games with KCSO

Payment:

Please make sure to submit your payment to any board member.