Medical Addendum For Down Syndrome Form - Special Olympics Oklahoma
Download a blank fillable Medical Addendum For Down Syndrome Form - Special Olympics Oklahoma in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Medical Addendum For Down Syndrome Form - Special Olympics Oklahoma with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1M
A
A
D
S
EDICAL
DDENDUM FOR
THLETES WITH
OWN
YNDROME
S
O
O
PECIAL
LYMPICS
KLAHOMA
This form must be completed and signed by the examining physician for individuals with Down Syndrome wishing to participate in Special Olympics. All
athletes with Down Syndrome must have this form on file in the State Office to be eligible to participate in Special Olympics Oklahoma. Please complete the
entire form accurately and mail to: Special Olympics Oklahoma - 6835 S. Canton Avenue, Tulsa, OK., 74136 - ATTN: Program Department
Athlete Name _______________________________________________________________________________________________________________
Sex: Male
Female
Age _______________________
Birthdate (Mo/Day/Yr) ____________________________________
Parent / Guardian Name ______________________________________________________________________________________________________
Primary Email Address _______________________________________________________________________________________________________
Day Phone _________________________________________________
Cell Phone _____________________________________________________
NOTE TO EXAMINING PHYSICIAN: Studies show that approximately 10% of persons with Down Syndrome have the condition of Atlantoaxial Instability.
Special Olympics Oklahoma requires cervical spine X-rays including full flexion & full extension views in order to determine the existence of AAI.
PHYSICIAN STATEMENT
: On examination of cervical spine X-rays including full flexion & full extension views, I find - please check box below:
No evidence
of Atlantoaxial Instability.
(Indicate below if the athlete has No Restrictions – or mark those sports in which the athlete MAY participate).
Positive evidence
of Atlantoaxial Instability.
(Indicate below all sports in which the individual may safely participate).
I have notified the parents/guardians
of the nature and extent of the condition. Yes *
No
Not Applicable
*If positive for AAI, a completed copy of the Special Release for Athletes with Atlantoaxial Instability must be submitted to the State Office in
Tulsa to be kept on file with this Addendum. Call to request the form: 918/481-1234 or 800/722-9004.
It is my recommendation that this athlete be allowed to participate in the following sports/events. Check boxes.
~ If athlete is able to participate in ALL sports/events, check the NO RESTRICTIONS box.
*
Indicates High Risk Sports - dangerous for positive Atlantoaxial Instability athletes.
AQUATICS * : Backstroke Breaststroke Butterfly
MUSIC: Dance * Vocal Instrumental
Combination Freestyle Diving Start
POWERLIFTING: Deadlift Bench Press Squat
(T&F) Running Events - Softball Throw – Jav -
ATHLETICS:
Standing/Running Long Jump - Shot Put
SOCCER: Individual Skills Team Competition
High Jump* Pentathlon* Race Walking
SOFTBALL: Individual Skills Team Competition
BOCCE: Individual or Team
VOLLEYBALL: Individual Skills Team Competition
BOWLING: Singles Doubles Unified Team
WHEELCHAIR EVENTS: 25 M Race 30 M Slalom
BASKETBALL: Individual Skills Team Competition 3-on-3
WINTER SPORTS * : Ice Skating Downhill Skiing
GOLF: Individual Skills
9-hole Play
18-hole Play
YOUNG ATHLETES PROGRAM: Sports Introduction
HORSESHOES: Individual or Team
NO RESTRICTIONS
EQUESTRIAN * : English or Western riding / rodeo events
Athletes w/ positive AAI are NOT eligible
________________________________________________________
____________________________________________________________
Name of Physician (PRINT)
Area Code & Phone Number (Office #)
________________________________________________________
___________________________________________________________
Signature of Physician
Date
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical