Volunteer Application and Unified Sports® Partner Release
REV 8-16
In accordance with the Special Olympics Volunteer Screening Policy and with the interest of the health and safety of all participants in mind, we ask
your cooperation by fully completing the requested information. ALL information is required and confidential.
Please Print All Information Legibly. This is a two-page application
Complete LAST Name Complete FIRST Name, NO nick name Complete MIDDLE Name, NO Middle Initial
Gender
Female Male
Date of Birth: ______/_____/_____
Month Day Year
**
____________/________/____________
Social Security Number for Applicants 18 & Older
**A social security number is OPTIONAL to perform a background check. Criminal background checks are required of all adult Special Olympics Maryland,
volunteers, Unified Partners, and employees.
Home Street Address
City State County Zip Code
Email address Primary Phone: Please check box - Home Cell
Employer/School: _______________________________________________ Occupation/Position: _________________________________________
Employer/School Address: _____________________________________________________________________________________________________
City: ___________________________________ State: __________ Zip Code: __________________
Emergency Contact Information (ALL INFO REQUESTED IS REQUIRED):
Emergency Contact Name: ____________________________________________________________________________
Relationship to you ______________________________Primary Phone Number: ________________________________
ADULT volunteers/partners, please list (1) adult, non-family reference: please print all information
Individuals 17 years old or younger must complete the separate Student/Minor Reference Form
Reference: *Complete Name: _______________________________________________________________________
Home Address: __________________________________________________________________________________
City: ___________________________________________ State: ______________ Zip: ___________
*Primary Phone Number: (____) _____________________________
FOR LICENSED MEDICAL PROFESSIONALS ONLY. Please List your Medical Credential ___________________
Please provide a copy of your current medical license or certificate with this application
Please answer the following questions:
1. Do you use illegal drugs? YES NO
2. Have you ever been convicted of, or granted probation before judgment for:
a) A criminal offense OR YES NO
b) Driving while impaired, intoxicated, or under the influence of alcohol or drugs? YES NO
3. Have you ever been charged (as an adult or juvenile) with neglect, abuse or assault? YES NO
4. Has your driver’s license ever been suspended or revoked in any state or other jurisdiction? YES NO
5. Within the past five (5) years, have you been at fault for two (2) or more
traffic accidents, or had your automobile insurance cancelled for safety reasons? YES NO
Please read each statement before signing: I do hereby understand and confirm that:
I have completed the General Orientation/Protective Behaviors session for volunteers and have been educated on the Special Olympics Maryland Volunteer Code of
Conduct and SOMD’s general procedures for protecting athletes from abuse. I agree to abide by these guidelines for the benefit and safety of all participants in the
Special Olympics Program;
I give my permission to Special Olympics Maryland to verify the information I have given and to conduct a criminal background screening and/or driving record
screening;
I authorize others to make available to any duly authorized representative of Special Olympics Maryland any information relevant to my volunteer application or status,
and I waive any right I may have with regard to the release of this information to Special Olympics Maryland;
I agree to indemnify and hold harmless Special Olympics Maryland, Special Olympics Inc., and any person to whom this request is presented and their agents and
employees, from and against all claims, damages, losses and expenses, including reasonable attorneys’ fees arising out of this request;
in the course of volunteering for Special Olympics Maryland, I may be dealing with confidential information, and I agree to keep that information in the strictest
confidence;
the relationship between Special Olympics Maryland and volunteers is an “at will” arrangement, and it may be terminated at any time without cause by either the
volunteer or Special Olympics Maryland;
I grant Special Olympics Maryland permission to use my likeness, voice and words in television, radio, film or in any form to promote activities of Special Olympics
Maryland;
I am responsible for informing Special Olympics Maryland of ALL changes regarding information contained in this application, and that I may be asked to provide
updated information at any time.
In consideration of participating in Special Olympics Maryland activities, including Unified Sports, I represent that I understand the nature of the event and that I (and/or
my minor child) am (are/is) qualified, in good health and in proper physical condition to participate in Unified Sports events. I fully understand the event may involve
risks of serious bodily injury which may be caused by my own actions or inactions, by the actions of others participating in the event, or by conditions in which the event
takes place. I fully accept and assume all such risks and all responsibility for losses, costs, and/or damages I (and/or my minor child) may incur as a result of my (and/or
my minor child’s) participation. I acknowledge that at any time that if I (we) feel that the event conditions are unsafe; I (and/or my minor child) will discontinue
participation immediately.
If during participation in Special Olympics Maryland activities I should need emergency medical treatment and I (and/or my minor child) am (are/is) not able to give
consent for or make my own arrangements for that treatment because of my injuries, I authorize Special Olympics Maryland to take whatever measures are necessary to
protect my health and well-being including, if necessary, hospitalization.
I (and/or my minor child) release, indemnify, covenant to sue and hold harmless Special Olympics Maryland, Special Olympics Inc., its administrators, directors, agents,
officers, volunteers, employees and other Unified Sports participants and sponsors, advertisers, and if applicable, any owners and lessors of premises on which the
activity takes place from all liability, any losses, claims (other than that of the medical accident benefit) demands, costs, or damages that I (or my minor child) may incur
as a result of participation in Special Olympics Maryland activities, including Unified Sports events, and further agree that if, despite this “Release and Waiver of Liability,
Assumption of Risk and Indemnity Agreement” I or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save and hold harmless each of
the Releasees from any litigation expenses, attorney fees, loss, liability, damage or cost which may incur as a result of such claim.
SOMD Housing Policy Information
The health and safety of all Special Olympics Maryland participants is of paramount importance to Special Olympics Maryland. Participants should feel that every Special Olympics Maryland
event is a safe and positive experience and should not be fearful of other participants, coaches or volunteers. Athletes will be matched for housing based on size, level of maturity, ability and
age. Each member of the delegation shall be assigned his/her own bed. Athletes and volunteers may not share a room with an athlete or volunteer of the opposite sex *. The
chaperone/athlete ratio of at least one properly registered chaperone to every four athletes must be maintained during overnight events. All chaperones must be screened in accordance with
the Special Olympics Volunteer Screening Policy.*See complete Special Olympics Maryland Housing Policy for allowed exceptions. The complete Special Olympics Maryland Housing Policy
can be found at www.somd.org.
Concussion Information
A concussion is a brain injury and all brain injuries are serious. They are caused by a bump, blow, or jolt to the head, or by a blow to another part of the body with the force transmitted to the
head. They can range from mild to severe and can disrupt the way the brain normally works. Even though most concussions are mild, all concussions are potentially serious and may result
in complications including prolonged brain damage and death if not recognized and managed properly. In other words, even a “ding” or a bump on the head can be serious. You can’t
see a concussion and most sports concussions occur without loss of consciousness. Signs and symptoms of concussion may show up right after the injury or can take hours or days to fully
appear. If you/your athlete report any symptoms of concussion, or if you notice the symptoms or signs of concussion yourself, seek medical attention right away. Participants with the signs and
symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the participant especially vulnerable to greater
injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the participant suffers another concussion before
completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is
well known that athletes will often under report symptoms of injuries, and concussions are no different. As a result, education of administrators, coaches, parents and athletes is the key for
athlete safety. Any participant even suspected of suffering a concussion should be removed from the game or practice immediately. No participant may return to activity after an apparent head
injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the participant should continue for several hours. Special
Olympics Maryland, Inc. requires the consistent and uniform implementation of well-established return to play concussion guidelines that have been recommended for several years including
an participant who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time and may not return to play until the participant is
evaluated by a licensed heath care provider trained in the evaluation and management of concussion and has received written clearance to return to play from that health care provider. For
current and up-to-date information on concussions you can go to: http://www.cdc.gov/Concussion
I affirm that I have read and understand this Volunteer Application and that the information given is true and complete. I have read the “Release and Waiver of Liability, Assumption
of Risk, and Indemnity Agreement” and fully understand and agree to it. I also understand that in the event false information is provided, I may be terminated from my volunteer
position.
Applicant Signature: __________________________________________________________________ Date: ___________________________
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
IF APPLICANT IS A MINOR:
Individuals 17 years old or younger must also complete the separate Student/Minor Reference Form
Parent/Guardian Name: ________________________________________________________ Relationship to Applicant: Parent Guardian Other_________________
Signature of Parent/Guardian: ______________________________________________________________________ Primary Phone #: ___________________________
_________________________________________________________________ Date: ___________________
Signature of Special Olympics Maryland Staff or Authorized Representative Photo ID Provided: Yes NO
SIGN
SIGN
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome