Minor Class 'A' Volunteer Application
Part 1 - Basic Information
Part 2 - Volunteer Roles (Please check all that apply to your status with SOCT)
Part 3 - Health Information
Do you have any condition that would affect your ability to participate in any of the duties listed above?
Please explain. (Your answer will be kept strictly confidential and only be used for safety purposes.)
Part 4 - Background Information
Do you use any drug that would affect your ability to perform any of the duties listed above?
Have you ever been convicted of a crime?
Have you ever been reported to the Department of Children and Families or a comparable child welfare agency with a finding of abuse or neglect against you?
Has your drivers' license ever been suspended or revoked as a result of a moving violation in any state?
I agree to the following:
1. Ability to Participate. I am phsically able to take part in Special Olympics activities.
2. Likeness Release. I give permission forever to Special Olympics, Inc or Special Olympics Connecticut, Inc. Special Olympics Games Organizing Committees, and any Special Olympics accredited program and Special Olympics partners and sponsors to use my likeness, photo, video, name, voice, words, and biographical information to promote Special Olympics, raise funds for Special Olympics, and acknowledge partners' and sponsors' support for Special Olympics.
3. Risk of Concussion and Other Injury. I know there is a risk of injury. I understand the risk of continuing to participate with or after a concussion or other injury. I may have to get medical care if I have a suspected concussion or other injury. I also may have to wait 7 days or more and get permission from a doctor before I start playing sports again.
4. Emergency Care. If I am unable, or my guardian is unavailable, to consent or make medical decisions in an emergency, I authorize Special Olympics to seek medical care on my behalf.
5. Health Programs. If I take part in a health program as a participant, I consent to health activities, screenings, and treatment. This should not replace regular health care. I can say no to treatment or anything else at any time.
6. Personal Information. I understand that Special Olympics will be collecting my personal information as part of my participation, including my name, image, address, telephone number, health information, and other personally identifying and health related information I provide to Special Olympics (?personal information?).
- I agree and consent to Special Olympics:
o using my personal information in order to: make sure I am eligible and can participate safely; run trainings and events; share competition results (including on the Web and in news media); provide health treatment if I participate in a health program; analyze data for the purposes of improving programming and identifying and responding to the needs of Special Olympics participants; perform computer operations, quality assurance, testing, and other related activities; and provide event-related services.
o sharing my personal information with (i) researchers, such as universities and public health agencies, that are studying intellectual disabilities and the impact of Special Olympics activities, (ii) medical professionals in an emergency, and (iii) government authorities for the purpose of assisting me with any visas required for international travel to Special Olympics events and for any other purpose necessary to protect public safety, respond to government requests, and report information as required by law.
o using my personal information for communications and marketing purposes, including direct digital marketing through email, text message, and social media.
- I have the right to ask to see my personal information or to be informed about the personal information that is processed about me. I have the right to ask to correct and delete my personal information, and to restrict the processing of my personal information if it is inconsistent with this consent.
7. Background Check Authorization. [APPLIES TO ADULTS ONLY] I authorize Special Olympics to conduct a background check on me. This background check may be done through a third party. The background check may include an inquiry into my employment, education, driving, and/or criminal history. I understand that Special Olympics may rely on information provided or discovered to determine whether I may participate in Special Olympics activities. By signing below, I authorize investigators to conduct a background check as described in this form. I further authorize any third parties or agencies who may be in possession of the requested information, to disclose such information in connection with this background check.
8. Waiver and Liability Release. I understand the risks involved with participation in Special Olympics activities. I fully accept and assume all such risks and all responsibility for losses, costs, and damages I may incur as a result of my participation. I hereby release and agree not to sue any Special Olympics organization, its directors, agents, volunteers, and employees, and other participants (?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. 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.
9. I affirm that I have read the above and that the information I have given is true and complete.
10. The relationship between Special Olympics Connecticut and volunteers is an "at will" arrangement, and this application may be denied or the relationship may be terminated for any reason.
11. In the course of volunteering for Special Olympics Connecticut, I may be dealing with confidential information and I agree to keep said information in the strictest confidence.