<p> Brenham Independent School District Special Olympic Athlete Medical Information</p><p>Name ______DOB ______Age ______Campus______Grade ______Parents/Guardians ______Address ______Telephone: Home ______Work ______Cell ______</p><p>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).</p><p>______</p><p>______</p><p>______</p><p>Does the student take medication?  YES  NO List medication taken: ______Dosage: ______</p><p>What effect does the medication have on physical activity?</p><p>______</p><p>______</p><p>Date of last tetanus vaccination ______</p><p>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.) ______</p><p>______</p><p>______</p><p>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</p><p>Emergency Information Alternate Emergency Contact Information:</p><p>Name ______Relationship ______Telephone: Home ______Work ______Cell ______</p><p>______Signature of Parent Date</p>