Special Provisions Regarding Medical Treatment (Religious Objections Form)

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TO BE COMPLETED BY ADULT ATHLETE 1. I agree to carry with me, at all times during my participation in any Special Olympics training or competition event, a printed card or paper that describes my religious objection, so that in case I get sick or hurt and cannot speak for myself, Special Olympics will be able to read this card and learn of my religious objections to medical treatment. 2. I also agree to make arrangements for an adult friend or member of my family to be present with me on site at all times during my participation in Special Olympics activities, so that this person can take personal responsibility for me if a medical emergency arises and I am unable to speak for myself. I understand that if this friend or family member is not present, I will not be permitted to participate in that event, and that no exceptions will be made. 3. I also agree to release Special Olympics and their employees and volunteers from any and all claims, demands or liabilities of any kind that may arise out of Special Olympicsʼ failure to take measures to provide me with emergency medical treatment during Special Olympics events and activities. I am agreeing to this release because I have refused, knowingly and voluntarily to give Special Olympics permission to take such emergency measures, and I am expressly directing Special Olympics not to do so, on religious grounds. I have read this release. I fully understand what it says and I agree to it.

TO BE COMPLETED BY PARENT/GUARDIAN OF MINOR ATHLETE 1. I agree to be present with the athlete at all times at the site of any Special Olympics training or competition events in which the athlete will participate, so that I can be readily available to take personal responsibility for the athlete if a medical emergency arises. I understand that if I am not present, the athlete will not be permitted to participate in that event and that no exceptions will be made. 2. I also agree on behalf of myself and the athlete, to release Special Olympics and their employees and volunteers from any and all claims, demands or liabilities of any kind that may arise out of Special Olympicsʼ failure to take measures to provide the athlete with emergency medical treatment during Special Olympics events and activities. I am agreeing to this release because I have refused, knowingly and voluntarily to give Special Olympics permission to take such emergency measures, and I am expressly directing Special Olympics not to do so, on religious grounds. I have read this release. I fully understand what it says and I agree to it

Signature of Parent/Guardian

First Last

Signature of Adult Athlete

First Last

Date