Special Olympics Ohio new Medical and
Release Forms
Special Olympics Incorporated has issued new medical and release forms that State
Chapters must begin using. Special Olympics Ohio 2012 (version) medical forms that are
dated prior to April 1, 2017 will still be valid for 3 years as of the physician’s signature.
After this date, all programs must use the new forms that are attached.
Please print clearly on this form
Health History
Pages 1-2 need to be filled out prior to the athlete’s medical examination. The name of
person completing pages 1 and 2 needs to be filled out on the bottom of page 2. Please
fill out as much information as possible.
Areas on page (1) one that must be filled out include: Athlete’s name, age and gender.
On page (2) two: athlete’s name and person completing the form
Athlete Release Form
Page 3 is the Athlete Release form this page needs to be filled out and signed by a
parent or guardian. If the athlete is signing the form and is over 18 they need to sign at
the participant signature line. There are no changes that can be made to the wording on
this form for an athlete to be allowed to participate. There must be a signature and date on
this form.
Physical Examination
Make sure the athlete’s name is filled out at the top of this form, all information the doctor
feels comfortable completing will be accepted. A doctor’s signature and date must be
on page 4 of this form, no attached medicals or signatures will be accepted. The
doctor must fill out the recommendations area of participation.
Medical Referral Form
This page is only to be used if a doctor determines that an athlete needs further
examination to a specialist prior to any involvement in Special Olympics.
Special Olympics Ohio
3303 Winchester Pike, Columbus, 43232, Tel 614.239.7050 Fax 614.239.1873
www.sooh.org Twitter soohio
Created by the Joseph P. Kennedy Jr. Foundation for the benefit of persons with intellectual disabilities
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