Athlete First Name
Athlete Last Name

School/Organization

Mailing Address

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County

Home Phone Work Phone Cell Phone

E-mail Address

Other Information
Date of Birth January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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Have you ever participated in Special Olympics?

Does athlete have a current Special Olympics Kentucky Medical?

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Parent/Guardian Information:

First Name Last Name

Organization

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Home Phone Work Phone Cell Phone

E-mail Address

Have you ever participated in Special Olympics?

Are you interested in coaching Special Olympians?

Are you interested in chaperoning Special Olympians?

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IMPORTANT NOTE: Submitting this form DOES NOT complete the registration process for an athlete to be eligible for Special Olympics participation. The potential athlete's physician still must complete a Athlete Medical Release Form before and athlete can begin training or competing in the program.

CURRENT SPECIAL OLYMPICS COACHES: Submitting this form DOES NOT register an athlete or athletes for a specific Special Olympics Kentucky competition. Please contact the proper Program Director for event registration information.

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