The purpose of this event is to provide fun and fellowship for some
of God’s very special people. It is not a sanctioned event of the
Special Olympics. Please pre-register by September 25, 2009
for event scheduling and to assure a T-shirt for the athlete.
Participant’s name: Sex: M F
Last First
Address:
City: St: Zip:
Age: Date of Birth: School/Organization Representing:
Telephone: Emergency #:
Parent/Guardian Name:
Physician: Telephone:
Any Special Medical Needs:
T-shirt size: CIRCLE Youth: S M L Adult:
S M L XL XXL XXXL
Please Circle Choices: Each participant is eligible
for 3 events!
25 Meter Dash
Soccer Kick
50 Meter Dash
Frisbee Throw
Softball Throw
Bean Bag Toss
Wheelchair Race & Wheelchair Obstacle race
Participant/Guardian Release
I hereby give permission for the entrant named above to participate
in the Special Olympic Fun Day sponsored by St. Ann Catholic Church. I
represent and warrant to you that the entrant named above is physically
and mentally able to participate in this track and field event.
I understand I will be responsible for any medical expenses for
myself/my child, if any, and do waive any legal right or claim against
St. Ann Catholic Church, Christian Brothers High School, The Catholic
Diocese of Memphis, Special Olympics or their staffs in the event of
injury by participation in any such activity or travel to and from any
such activity.
Please note the POLICY requiring one adult (parent or
guardian) for each athlete and must be present all day. This one-to-one
ratio is a liability issue that we appreciate your help with.
By signing this form I authorize the sponsors’ staff members to
administer first aid, contact our family physician for medical
treatment, summon emergency medical care, or transport me/my child to a
medical facility for treatment.
Signature: Date:
Relationship to participant:
Day of event guardian: Cell_________________________
Mail by Sept 25 to St. Ann Special Olympics Fun Day 6529 Stage Rd
Bartlett, TN 38134
Fax to 901-373-9030, or email to:
mamag1@comcast.net
Memphis
Deaf Community
