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Athlete Registration Renewal Form

Name(Required)
Birth Date(Required)
Type of phone

General Health Questions:.

Health History

Health and/or mobility aids the athlete possesses and may use during Special Olympics participation.

Do you have a heart condition?(Required)
Have you ever had a head injury or concussion?(Required)
Do you have a bleeding disorder?(Required)
Do you have epilepsy or any type of seizure disorder?(Required)
Do you have behavioral, mental health, and/or sensory conditions that could impact your/other’s participation?(Required)
Do you have behavioral, mental health, and/or sensory conditions that could impact your/other’s participation?(Required)
Do you have asthma?(Required)
Do you have diabetes?(Required)
Do you have a vision impairment?(Required)
Do you have asthma?(Required)
Do you have a hearing impairment?(Required)
Do you have sickle cell disease?(Required)

Medication and Treatment.

Have there been any changes to your prescriptions, over-the-counter medications, or treatments?(Required)
please list dosages and times of day
If yes, please specify if it is to any of the following:(Required)
I certify the information provided on this form is true and correct to the best of my knowledge.
Is this form being completed by someone other than the athlete?
Is this form being completed by someone other than the athlete?
If yes, please select the relationship to athlete:

We at Special Olympics Mississippi are dedicated to helping people across the great Magnolia State by making everyone’s life healthier and more inclusive.

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