Athlete Name: 2018 SPECIAL OLYMPICS USA SUMMER GAMES Cover Sheet & Checklist Sport: Local Program: THE 2018 SPECIAL OLYMPICS USA NATIONAL SUMMER GAMES will be held July 1-6, 2018 in Seattle, WA. It is anticipated that 4,000 athletes and 1,000 coaches from the United States will compete in the USA Games. Below are the 6 competitive sports in which the USA Games Organizing Committee (GOC) has previously allotted to Special Olympics Kansas. Athletics (2 male & 2 female) Aquatics (2 male & 2 female) Bocce (2 male & 2 female) Bowling (2 male & 2 female) Tennis (2 male & 2 female) Powerlifting (1 male & 1 female) Following is the Special Olympics Kansas Delegation Athlete Information Packet for the 2018 USA Summer Games. This packet includes initial information required for registration by the Kansas Delegation on each selected athlete. We ask that athletes (with assistance from Coaches and Family Members) complete this information if they are interested in participating on the Kansas Delegation. Please answer HONESTLY. There is no single-answer disqualifier. Each Special Olympics athlete is unique and needs support/assistance in different ways. Special Olympics Kansas Staff and Coaches are prepared and willing to provide assistance, mentorship, supervision and guidance. We only have enough coaches to provide 1-to-4 supervision (coach-to-athlete). Table of Contents Completed? Pg 2 Athlete Selection Requirements Yes No Pg 3 Athlete Code of Conduct and Signature Yes No Pg 4 Athlete Information Yes No Pg 5 Sports Training and Information Yes No Pg 6 Medical Overview Yes No Pg 7 Self-Help Skills Yes No Pg 8 Behavior Yes No Pg 9 Travel Experience Yes No ALL completed forms from this packet should be emailed (preferred), faxed or postmarked by April 15, 2017: Clint Armistead (armisteadc@ksso.org) with copy to Tim Rehder (rehdert@ksso.org) Special Olympics Kansas 2018 USA Games Athlete Application 5280 Foxridge Dr Mission, KS 66202 Fax # 913-236-9771 **Do NOT send information on CD or thumb drive.** Incomplete forms will not be accepted. For questions, please contact Clint Armistead (armisteadc@ksso.org) or 913-236-9290x111. Special Olympics Kansas, USA Games Athlete Application Page 1 of 9 Revised 3/10/2017
Athlete Name: 2018 SPECIAL OLYMPICS USA SUMMER GAMES Athlete Selection Requirements Sport: This athlete demonstrates good sportsmanship, love for the sport, and the ability to function well as a part of a team. The athlete is not only be dedicated to their sport, but is also able to commit extra time to training, travel to training sessions, and be involved in other USA Games activities as determined by the Head of Delegation. Athletes must be from a registered Special Olympics Kansas Local Program. Athletes must have competed in their respective sport for 2 years with SOKS prior to the USA Summer Games. Recommended age is 16, exceptions can be made by contacting the Head of Delegation. Athletes selected must train for one year as outlined by his/her Sport Coach, including in-person training sessions. This may require athletes to be away from home and work. Athletes must attend State Training Sessions which will be scheduled in conjunction with 2017 State Summer Games, 2017 State Fall Sports Classic, and 2018 State Basketball competitions. Athletes must identify a local coach to coordinate with the Kansas Delegation Sport Coach to train the athlete. Athletes will be assigned to a Kansas Delegation Sport Coach for the duration of their travel to/from the Games, during the Games, including in the housing site and competition venues, and during Delegation training session(s) prior to the Games. Family/legal guardian or Local Program contact must attend all required meetings and orientations as outlined by the Head of Delegation. Athletes are subject to pre-delegation selection screening (Athlete Selection Criteria, Athlete Information Form, Athlete Medical, and Training Session) to be conducted by SOKS. Athletes must be able to handle long days (12-18hrs) independently or with minimal supervision (1:4 coach-to-athlete ratio). Athletes must adhere to the Special Olympics Kansas Delegation Code of Conduct. Athletes must be able to be away from their families and jobs for approximately a one (1) week period in July 2018 to attend the Games (exact travel dates will be available at a later date). Athletes must be able to semi-independently manage the activities and skills of daily living, such as toileting, showering, personal hygiene, etc. Travel to and from training sessions, the send-off and return locations for the Kansas Delegation are not provided and is the responsibility of the athlete, family, or Local Program Athletes may be removed from the Delegation, at any time, for failure to adhere to the principals or fulfill the responsibilities of the criteria as set forth by Special Olympics Kansas and/or Special Olympics North America. Athletes may be removed from the Delegation for health and safety issues. Participation in Fundraising is mandatory. Athletes must raise 50% of the funds required (SOKS picks up the other 50%). When divided evenly, athletes may be expected to $1000. Does this athlete meet the selection criteria outlined above? Yes No Special Olympics Kansas, USA Games Athlete Application Page 2 of 9 Revised 3/10/2017
Special Olympics Athlete s Code of Conduct Special Olympics is committed to the highest ideals of sport and expects all athletes to honor Sports and Special Olympics. All Special Olympics athletes and Unified Partners agree to the following code: I) SPORTSMANSHIP A) I will practice good sportsmanship. B) I will act in ways that bring respect to me, my coaches, my team, and Special Olympics. C) I will not use bad language. D) I will not swear or insult other persons. E) I will not fight with other athletes, coaches, volunteers, or staff. II) TRAINING AND COMPETITION A) I will train regularly. B) I will learn and follow the rules of my sport. C) I will listen to my coaches and the officials and ask questions when I do not understand. D) I will always try my best during training, divisioning, and competitions. E) I will not hold back in preliminaries just to get into an easier final heat. III) RESPONSIBILITY FOR MY ACTIONS A) I will not make inappropriate or unwanted physical, verbal, or sexual advances on others. B) I will not drink alcohol, smoke (including tobacco) or take illegal drugs while representing Special Olympics at training sessions, competition or during Games. C) I will not take drugs for the purpose of improving my performance. D) I will obey all laws and Special Olympics rules. We have read and understand the Athlete Selection Requirements and Athlete Code of Conduct I understand the expectations of athletes selected to the Kansas Delegation, and believe this athlete meets the requirements as outlined and wants to be a part of the Kansas Delegation. We understand an athlete may be traveling and/or coached by an individual from another part of the state. We understand Special Olympics Kansas may remove an athlete from the delegation if he/she fails to meet the Athlete Selection Criteria or acts outside the Athlete Code of Conduct. The information we have provided is true and complete. Signature of Athlete Date Check here if athlete is their own legal guardian Signature of Parent/Legal Guardian Date Special Olympics Local Program Coordinator Section We have read and understand the Athlete Selection Requirements and Athlete Code of Conduct. We understand the expectations of athletes selected to the Kansas Delegation. We have met/interviewed this athlete and believe he/she meets the requirements as outlined and wants to be a part of the Kansas Delegation. Signature of Local Program Coordinator Date Signature of Local Coach Date Special Olympics Kansas, USA Games Athlete Application Page 3 of 9 Revised 3/10/2017
Athlete Information Full Legal Name: (First): (Middle): (Last): In which sport is this athlete applying for the Games? *may be considered for up to 2 sports Mailing Address: Is there a different first name you prefer to go by? City, State, Zip: Email: @ Gender: Male Female Date of Birth: / / Preferred Phone: ( ) Best Time to Call: Languages other than English spoken fluently (please list): SOKS Local Program: T-Shirt Size (adult unisex): Additional Contact Information Is the athlete completing this information form their own legal guardian? Yes No First Name: Mailing Address: Parent/Legal Guardian Last Name: City, State, Zip: Day Phone: ( ) Eve. Phone: ( ) Cell Phone: ( ) Fax: ( ) Best Time to Call: Email Address: @ First Name: Mailing Address: Emergency Contact (if different from above) Last Name: City, State, Zip: Day Phone: ( ) Eve. Phone: ( ) Cell Phone: ( ) Fax: ( ) Best Time to Call: Email Address: @ Relationship to Athlete: First Name: Mailing Address: Local Coach (person who will train athlete locally to prepare for 2018 Games) Last Name: City, State, Zip: Day Phone: ( ) Eve. Phone: ( ) Cell Phone: ( ) Fax: ( ) Best Time to Call: Email Address: @ Special Olympics Kansas, USA Games Athlete Application Page 4 of 9 Revised 3/10/2017
Sports & Training Information For which sport is the athlete applying? *select up to 2 sports Athletics Bocce Bowling Powerlifting Swimming Tennis How many years has the athlete trained in this sport? <1yr 1-2yrs 2-5yrs 5+yrs Does athlete own the needed equipment/shoes/training wear for this sport? Yes No Does athlete have access to a training center? (ie bowling alley, swimming pool, etc) Yes No Current Sport Performance Metrics Athletic prowess is not a requirement. See Page 2 for Selection Requirements For Swimming Only: For Athletics Only: For Powerlifting Only: Event Avg. Time N/A Event Avg. Time/Dist N/A Max. Lift N/A 25 Freestyle : 100M Run : Bench. lbs 25 Backstroke : 200M Run : Deadlift. lbs 25 Butterfly : 400M Run : Squat. lbs 25 Breaststroke : 800M Run : Weight Class 50 Butterfly : 1500M Run : For Bowling Only: 50 Breaststroke : Shot Put. m 3 Game Avg. Score 50 Freestyle : Long Jump. m For Tennis Only: 50 Backstroke : Mini Jav. m Match Play Level 100 Freestyle : For Bocce, no score required. Skills Assessment required at later date Has this athlete competed previously at a USA or World Games? Yes No If yes, what If yes, what year(s)? sport(s)? Does the athlete have a current Athlete Medical and Consent Form on file with SOKS? Yes No If yes, what is the expiration date of the medical? / / Will this athlete commit to a 52-week training program developed by his or her Kansas Delegation Sport Coach prior to the Games? Yes No Will the athlete attend the State Training Sessions scheduled in conjunction with 3 State Games? If no, please state why: Yes No Is this athlete prepared and capable of spending approximately one (1) week away from home, school or work in July 2018 for the USA Summer Games? Yes No Will the athlete be available to attend June 30 -July 7, 2018 for the 2018 USA Summer Games? Yes No Will the athlete commit to fundraising requirements? Yes No Special Olympics Kansas, USA Games Athlete Application Page 5 of 9 Revised 3/10/2017
Medical Overview This section will supplement the Athlete Waiver/Medical required to participate in the USA Games. Please check all that apply to this athlete: Allergies Depression Medical Device/Implant Special Diet Asthma Diabetes Mental Illness Surgery (within last year) Atlanto-axial Instability Glasses/Contacts Motion Sickness Uses Cane, Walker, etc. Autistic Hearing Impaired Non-verbal Uses Wheelchair Broken Bones (major/recent) Hepatitis Seizures Does this athlete take any medications? If yes, please list below & attach extra sheets if needed. Yes No Medication Name Dosage Times Taken per Day Method of delivery (oral, injection, Special Instructions inhalation, (refrigeration, take with food, topical, etc) etc) Can this athlete take medications without assistance? Yes No Is this athlete susceptible to colds, infections, etc? Yes No If female, has this athlete ever menstruated? Yes No If yes, is her cycle consistent? Yes No What feminine hygiene product(s) can she use? Sanitary Napkins Tampons Either Special Olympics Kansas, USA Games Athlete Application Page 6 of 9 Revised 3/10/2017
Behavior All athletes are unique and pursue personal goals. It s rare for any athlete to have zero behavior concerns. Please be HONEST. The Kansas Delegation needs the most complete knowledge and understanding in order to provide a positive experience for the athlete and other athletes, and to positively promote Special Olympics. Behavior Concerns Does not exhibit behavior 1 2 3 4 5 6 7 8 9 Common behavior concern 10 Bites self or others Cries or becomes upset easily Difficulty changing routines Difficulty with authority Difficulty taking direction Elevated emotional needs Sexual interest Exaggerates pain/illness Cursing/vulgarity Excessive physical touching Hits self or others Overly fearful Pulls own hair or others hair Resistant to changes in diet Seeks steady attention Seeks steady entertainment Teases others Temper tantrums Throws objects Uncomfortable in crowds Wanders/runs from group Explain behavior and/or specific methods to resolve behavior concerns: Special Olympics Kansas, USA Games Athlete Application Page 7 of 9 Revised 3/10/2017
Self-Help Skills Every athlete is unique and works towards individual goals of independence. Please be HONEST. The Kansas Delegation needs the most complete knowledge and understanding in order to provide a positive experience for the athlete and other athletes, and to positively promote Special Olympics. Life Skill Entirely independent 1 2 3 4 5 6 7 8 9 Dressing Grooming Mealtime Toileting Dependent on others 10 Elaborate, if necessary Do you think this athlete will relate and respond successfully to an unfamiliar coach and environment? Yes No If no, please explain: How long does the athlete take to get out of bed, groom & dress each morning? <15mins 15-30mins 30mins- 1hr 1+hrs In evaluating this athlete s behavior and self-help skills, what level of coach support would be required to be successful? Requires little to no support. Athlete could, or does, live on their own. Requires moderate support. Supervision within a group of 4 athletes to 1 coach would be acceptable. Requires significant support. Supervision on a 1- to-1 basis would be needed. Special Olympics Kansas, USA Games Athlete Application Page 8 of 9 Revised 3/10/2017
Travel Experience Has this athlete ever traveled by bus? Yes No Has this athlete ever traveled by airplane? Yes No Has this athlete ever traveled by train? Yes No Is this athlete claustrophobic? Yes No Does this athlete have emotional discomfort when traveling (homesickness, anxiety, mood swings)? Yes No If yes, please explain: How long has this athlete taken a trip without a family member/legal guardian present? <24hrs 1-2days 3-6 days 1+ weeks Can this athlete carry/move their own luggage (suitcase and carry-on) and equipment? Yes No Can this athlete sit and reasonably occupy oneself (movies, music, ipad, puzzle books, etc) for an extended period of time such as on a flight or waiting for competition to begin? Yes No The Kansas Delegation will likely have early morning and late evening travel. What concerns are there for this athlete to be up and moving early in the morning and/or active late at night? NOTE: Non-Delegation members, such as family members, friends, or other athletes, will not be allowed to travel with the Special Olympics Kansas Delegation to the Games. Nor will there be a possibility to room with the Kansas Delegation nor have access to Delegation dorms/hotel rooms. In general, access to meet with the athletes during the Games will be extremely limited. Special Olympics Kansas, USA Games Athlete Application Page 9 of 9 Revised 3/10/2017