Annual Registration – KCSO Family & Friends

Is Athlete new to KCSO? *

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Athlete Given Name *

First

Last

Nickname - if any:

Athlete Birthdate *

Address

Address Line 1

City

State

Zip Code

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#1 Parent/Guardian Name *

First

Last

#1 Athlete Parent/Guardian Email Address *

#1 Parent/Guardian Phone Number *

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#2 Parent/Guardian Name

First

Last

#2 Athlete Parent/Guardian Email Address

#2 Parent/Guardian Phone Number

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Emergnecy Contact *

First

Last

Emergency Contact Phone Number *

Medical Information

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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: *

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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:

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Acknowledgements:

Does Athlete need assistance with registration fees: *

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Medical Applications: I understand that my athletes medical application with Special Olympics Illinois must be current by the first practice of any event they will not be able to participate in that event. *

I accept

Illness: I understand that if my athlete or any family member attending events are ill - they will not attend any practice, event or competition. *

I accept

Practices: I understand that if my athlete does not attend at least 80% of practices, they may not be able to compete in any given sport. *

I accept

Registration Fees: I understand that if I do not pay the registration fees by the first practice of any sport, my athlete will not be able to participate until paid. *

I accept

I, the below signed, agree to abide by all the rules and expectations of each sport. I will also support my athlete by encouraging them, agreeing and abiding by the Special Olympic Athlete oath and code of conduct, represent KCSO at all practices, competitions, trips and events with a respectful and positive attitude. Noncompliance to this agreement may result in a partial exclusion from practice or competition by the head coach. A total exclusion from one or more sports may occur after a review by the KCSO Executive Board. Typing your name here serves as an on-line signature.

Name *

First

Last

Payment:

Annual Registration Fee Payment *

Annual Registration Fee - $ 40.00
Pay by Check/Cash at 1st Practice - $ 0.00
Scholarship - $ 0.00

Total

$ 0.00

Enter Credit Card *

Card

Name on Card

EmailPymnt *

Email of Credit Card Holder

Annual KCSO Registration

Medical Information

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Acknowledgements:

Payment:

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