Healthy Young Athletes

Join Special Olympics Northern California for Healthy Young Athletes screening!

Healthy Young Athletes is a holistic pediatric screening offered to children 2–10 years old, with and without Intellectual Disabilities, as an initial offering by Healthy Athletes.

The screening complements your child’s primary care and provides an additional review of the child’s health and development. It is paired with a comprehensive referral and community support strategy as well as an educational experience to increase health and development knowledge amongst parents and caregivers!

Where:

University of San Francisco – Fromm Hall
2497 Golden Gate Ave, San Francisco, CA 94118

When: Saturday, April 26, 2025 from 10AM-1PM

Time: 10AM-1PM Appointments every 30 minutes

Cost: This is a FREE event

How it works:

Complete Registration below!
Come to the event with the Prescreening Survey completed OR email it to us ahead of time.
We’ll take care of the rest!

If you have problems with the registration form or if any questions arise, please email Health@sonc.org.

Healthy Athletes at Summer Games

Athlete Information

First Name

Last Name

Preferred name:

If different than First Name

Date of Birth

MM/DD/YYYY - Month/Day/Year - 01/24/2000

Phone

10 digit phone. Numbers only

Address

City

State

Zip Code

5 digit zipcode

Gender / Race / Language

Gender

Race/Ethnicity

Languages Spoken
Check all that apply

Hold Ctrl to select

Other Languages

Healthy Athletes Event Information

Check in Time

Do you have an URGENT concern in any of the following areas?

Audio	Dental
Fine Motor	Gross Motor
Language and communication	Nutrition and GI
Sleep	Social-emotional
Resources and Referrals	Thinking, reasoning, and problem solving
Visual

Other Concerns

Yes

Define Other Concerns

Parent/Guardian

First Name

Last Name

Date of Birth

MM/DD/YYYY - Month/Day/Year - 01/24/2000

Phone

10 digit phone. Numbers only

Address

City

State

Zip Code

5 digit zipcode

Relationship to Athlete

Name of Group Home (if applicable)

I am the emergency Contact

Yes

Emergency Contact - *please enter name of another individual who can be contacted in an emergency*

First and Last Name

Emergency contact must be someone besides the athlete

Phone

Enter 10 digit phone. Numbers only

Relationship to Athlete

Athlete Health Information

Associated Conditions (check all that apply)(optional)

Autism

YesNo

Cerebral Palsy

YesNo

Down Syndrome

YesNo

Marfan Syndrome

YesNo

Spina Bifida

YesNo

Fetal Alcohol Syndrome

YesNo

Fragile X Syndrome

YesNo

Please specify other known intellectual disability diagnoses:

Assistive Devices and Accommodations (please note any devices used)

Assistive Devices

Walker

YesNo

Braces or Crutches

YesNo

Wheelchair

YesNo

Prosthetics

YesNo

Removable Orthodontics

YesNo

Please list any additional assistive devices:

Lifestyle Aids (Optional)

Glasses, contact lenses, or protective eyewear

YesNo

CPAP

YesNo

Communications (Optional)

Hearing Aid

YesNo

Sign Language

YesNo

Communication Devices

YesNo

Provider information (Optional)

Primary Insurance Provider

Are you currently enrolled in Medicare?

YesNo

Are you currently enrolled in Medicaid?

YesNo

Please select all the healthcare providers you have access to:

Primary Doctor

YesNo

Eye Doctor

YesNo

Foot Doctor

YesNo

Ear Doctor

YesNo

Dentist

YesNo

Physical Therapist

YesNo

Mental Health Provider

YesNo

Regional Center

If you currently receive services from a Regional Center, please select one from this list.
If you do not receive services from any of them, please select "N/A."

Waivers, Releases and Policies

WAIVER & RELEASE OF LIABILITY / ASSUMPTION OF RISK / INDEMNIFICATION

In consideration of being allowed to participate in any way in Special Olympics activities, the undersigned acknowledges, appreciates, and agrees that:

While particular rules and personal discipline may reduce this risk, the risk of illness (including communicable diseases), injury (including concussion), disability, and death does exist;
If I observe any unusual or significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest Special Olympics representative immediately; and,
I understand the risks involved with participation in Special Olympics activities. I fully accept and assume all risks and all responsibility for losses, costs, and damages I may incur as a result of my participation. To the fullest extent of the law, I release and agree not to sue any Special Olympics organization, its directors, agents, volunteers, and employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable owners and lessors of premises on which any Special Olympics activity is occurring (“Releasees”) related to any liabilities, claims, or losses on my account caused or alleged to be caused in whole or in part by the Releasees even if arising from the negligence of the Releasees. I have read this release of liability and assumption of risk provision, fully understand its terms, acknowledge that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement. I further agree that if, despite this release, I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify and hold harmless each of the Releasees from any such liabilities, claims, or losses as the result of such claim. I agree that if any part of this form is held to be invalid, the other parts shall continue in full force and effect.

Parent/Guardian Agreement - by signing here, I recognize, and agree to, statements on this page

Parent/Guardian Name

Please use full name; applications without full legal names cannot be processed.

By checking this box, I attest that: first, I am legally able to sign on behalf of the applicant, and second, that I have read the above waivers, releases, and policies, and acknowledge and agree to them

By checking this box, I attest that the above field contains my signature