Conroe Independent School District s1

Brenham Independent School District Special Olympic Athlete Medical Information

Name ______DOB ______Age ______Campus______Grade ______Parents/Guardians ______Address ______Telephone: Home ______Work ______Cell ______

Medical Information Please describe any medical or physical condition(s) that could affect the student’s performance while engaged in physical activities including swimming. (Examples of conditions might be: allergies, asthma, nervous disorders, seizures, heart problems, diabetes, shunt, etc.) For allergies, be specific (ex. insect – wasp or food – nuts).

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Does the student take medication?  YES  NO List medication taken: ______Dosage: ______

What effect does the medication have on physical activity?

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Date of last tetanus vaccination ______

Please list any activities or movements that may cause harm to the student. (Example: can’t put head under water because of tubes in the ears or moving the leg away from the body will damage the hip joint, etc.) ______

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Atlanto – Axial Instability (AAI) results: (Down’s syndrome students only)  No evidence of Atlanto-Axial Instability Condition  Positive or equivocal evidence of Atlanto-Axial Instability Condition  X-ray report on file

Emergency Information Alternate Emergency Contact Information:

Name ______Relationship ______Telephone: Home ______Work ______Cell ______

______Signature of Parent Date