Special Release For Athletes With Atlanto-Axial Instability Form

SPECIAL RELEASE FOR ATHLETES WITH

ATLANTO-AXIAL INSTABILITY

CERTIFICATION BY PHYSICIANS

We have examined the athlete named in the application, who has Down syndrome and who has been diagnosed as having Atlanto-Axial Instability. We certify based on

our examinations of the athlete and our review of the health information contained in this application, that despite the diagnosis of Atlanto-Axial Instability, this athlete

is not medically precluded from participation in Special Olympics. We further certify that we have explained to the athlete named in this application, (and to the parent

or guardian whose signature appears below, if the athlete is a minor), the medical risks associated with Atlanto-Axial Instability and in particular, the risks associated

with the athlete’s participation in sports or events which, by their nature, may result in hyper-extension, radical flexion or direct pressure on the neck or upper spine.

(Signature of TWO physicians are required.)

Restrictions (if any): _______________________________________

Restrictions (if any): ________________________________________

________________________________________________________

_________________________________________________________

Physician’s Name:_________________________________________

Address:_________________________________________________

Phone:_(____)_________________________

Signature of

Physician_______________________________ Date:____________

CERTIFICATION OF ADULT ATHLETE

(Required for adult athletes with diagnosis of Atlanto-Axial Instability)

I am the athlete named in this application. I certify that:

I have been informed by the physicians named above that I have Atlanto-Axial Instability

The risks associated with that condition, including the risks from participating in equestrian sports, gymnastics, diving, pentathlon, butterfly stroke and diving

starts in swimming, high jump, alpine skiing, and soccer have been fully explained to me by the physicians named above, and I fully understand the possible

medical consequences if I participate in any of these sports or events.

Although I recognize and understand the risks and possible medical consequences, I certify that I am taking these risks knowingly and voluntarily, of my own free

will, because of my desire to participate in Special Olympics, including any of all of the sports listed above, based on the certifications of the two physicians

named above that I am not medically precluded from participating in Special Olympics

Name:________________________________________________________

Address:_______________________________________________________

Signature of Adult Athlete:_______________________________________________________________

Date: _______________________________

Signature of Adult Friend or Family Member:________________________________________________

Date: _______________________________

CERTIFICATION OF PARENT

(Required for minor athletes with diagnosis of Atlanto-Axial Instability)

I am the mother/father of the athlete named in this application. I certify that:

I have been informed by the physicians named above that my son/daughter has Atlanto-Axial Instability

The risks associated with that condition, including the risks from participating in equestrian sports, gymnastics, diving, pentathlon, butterfly stroke and diving

starts in swimming, high jump, alpine skiing, and soccer have been fully explained to me by the physicians named above, and I fully understand the possible

medical consequences if my son/daughter participating in any of these sports or events.

Although I recognize and understand the risks and possible medical consequences, I hereby give my permission for my son/daughter to participate in Special

Olympics, including any of all of the sports listed above, based on the certifications of the two physicians named above that my son/daughter is not medically

precluded from participating in Special Olympics

Name:________________________________________________________

Phone: ______________________________________

Address:______________________________________________________________________________________________________________________

Signature of

Parent/Guardian:_______________________________________________________________________

Date: _______________________________

(Revised December 2013)