Program Application 2017-2018

Please complete this Program Application to participate in Special Olympics Programs and Competitions. This application is for Traditional Delegations, Unified Delegations and School based programs.

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* 1. Part 1: Program Information

Program/School Name

School District

Program/ School Address

City/Town

ZIP Postal Code

School Enrollment #

Program/ School contact name

Phone Number / Cell

Fax

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* 2. I consent to receive the Special Olympics Arizona e-newsletter and event information

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* 3. Additional Program/ School Contacts.

Coach

Email:

Athletic Director

Email:

Teacher/ Para

Student Leader:

Email:

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* 4. Program Level (If registering as a district, please complete separate form for each school)

Preschool

Elementary School

Middle School

High School

College

Community Program

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* 5. Program Model Offered

Traditional

Unified

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* 6. Part 2: Program Participation
Mark each sport/program your delegation plans to participate in or would like information on:

Powerlifting

Volleyball

Tennis

Figure Skating

Swimming

Athletics (Track & Field)

Flag Football

Equestrian

Floorball

Cross Country Skiing

Snowboarding

Bowling

Soccer

Cheerleading

Snowshoeing

Unified Arts

Bocce

Golf

Kayaking

Speed Skating

Softball

Young Athletes

Basketball

Alpine Skiing

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* 7. I would like to receive information on area events

Yes

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* 8. Mark each program activity your delegation plans to participate in

Unified Arts

Unified Mobile Unit

R-Word/Spread the Word to End the Word Campaign (Must check to receive kit)

Minute that Matters

Fans in the Stands

Community based events

Sports Expo / Field Day

Healthy LEAP (Health Education)

Other (please specify)

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* 9. School Based delegations only:

Unified Sports Adaptive PE Curriculum

Unified Sports through Arizona interscholastic Association (AIA) *High School Only

Unified Activity (dance/ School Assembly)

Other (please specify)

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* 10. Inclusive Youth Leadership

Unified Clubs (Must Check to Receive a Unified Club Kit)

Youth Summit

Other (please specify)

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* 11. Please provide a brief description of fun activities or other creative ideas you might have during the year:

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* 12. Program / School Name:
Please check each item below to verify your acceptance
This program will follow, to the best of its ability, the rules and regulations of Special Olympics Inc. and Special Olympics Arizona, including but not limited to:

Enrollment of all Athletes and Partners (a current Athlete / Partner Medical Release & Consent Form on file with Head of Delegation and SOAZ state office for each Athlete / Partner.)

All coaches for this Delegation will have copies of each Athlete / Partners' Medical Release & Consent Form in their possession at all practices, competitions and other events.

I have reviewed the SOAZ Volunteer Application, Screening, and Training Policy and the SOAZ Coaches' Certification Policy.

All coaches for this Delegation have met (or will meet before holding their first practice) the certification requirements outlined in the current SOAZ Volunteer Application, Screening, and Training Policy and the SOAZ Coaches' Certification Policy.

Registration of all volunteers (current volunteer application forms on file/ approved).

I have reviewed Article 1 of the Special Olympics International Official General Rules.

Oversight of Special Olympics Code of Conduct of all volunteers, Athletes, Partners, and parents.

Adherence to all SOAZ fundraising policies/ procedures with respect to all funds raised in the name of Special Olympics Arizona.

I have reviewed and will adhere to all SOAZ accounting procedures with respect to funds raised and spent in the name of Special Olympics, cash advances, reimbursement requests, Purchase Orders, etc.

Acting as a communication liaison between the area / state office and program coaches, parents, Athletes and volunteers.

Refraining from entering into any written agreement (contracts) without approval from Area/ SOAZ offices.

Refraining from opening any school or bank accounts for this Delegation.

Attendance at all required meetings, trainings, opening ceremonies and conferences.

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* 13. Failure to Comply
Please check each item below to verify your acceptance"

This local program understands that failure to follow these agreements may result in immediate suspension of rights to conduct the Special Olympics program.

Under these conditions, I request accreditation as a local program under the supervision of Special Olympics Arizona.

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* 14. · I certify the information provided on this registration form is correct

· I will contact Special Olympics Arizona whenever program information changes or updates need to be made

· I understand all Athletes participating in Special Olympics must pass a sport physical. Partners under the age of 18 must complete a Unified Partner Form (SOAZ form). All other Partners must complete volunteer requirements.

· Each school based program will receive 2 participation update surveys per year (1 fall, 1 summer). Please prepared to answer the questionnaire by designated dates for reporting purposes.

Program / School contact signature (Please type full name):

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* 15. School Based delegations only:

Unified Strategies for Schools Department of Education funding request: Examples- transportation for Special Olympics events, Equipment, Uniforms, Teacher funded project, Student funded Project.

If you are a school based delegation please contact your Area Director for levels of support.

River Area Director, Lisa Ball, Lisa@SpecialOlympicsArizona.org
Mountain Area Director, Rubett Garcia, Rubett@SpecialOlympicsArizona.org or Jamie Heckerman, Jamie@SpecialOlympicsArizona.org
Monument Area Director, Eve Vance, Eve@SpecialOlympicsArizona.org
Palo Verde Area Director, Jamie Heckerman, Jamie@SpecialOlympicsArizona.org
Four Peaks Area Director, Eve Vance, Eve@SpecialOlympicsArizona.org
Coronado Area Director, Holly Thompson, HollyThompson@soaztucson.org
Support Services Office, Brittany Meola, Brittany@SpecialOlympicsArizona.org

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* 1. Part 1: Program Information

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* 2. I consent to receive the Special Olympics Arizona e-newsletter and event information

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* 3. Additional Program/ School Contacts.

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* 4. Program Level (If registering as a district, please complete separate form for each school)

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* 5. Program Model Offered

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* 6. Part 2: Program Participation Mark each sport/program your delegation plans to participate in or would like information on:

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* 7. I would like to receive information on area events

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* 8. Mark each program activity your delegation plans to participate in

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* 9. School Based delegations only:

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* 10. Inclusive Youth Leadership

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* 11. Please provide a brief description of fun activities or other creative ideas you might have during the year:

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* 12. Program / School Name:Please check each item below to verify your acceptanceThis program will follow, to the best of its ability, the rules and regulations of Special Olympics Inc. and Special Olympics Arizona, including but not limited to:

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* 13. Failure to ComplyPlease check each item below to verify your acceptance"

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* 6. Part 2: Program Participation
Mark each sport/program your delegation plans to participate in or would like information on:

* 12. Program / School Name:
Please check each item below to verify your acceptance
This program will follow, to the best of its ability, the rules and regulations of Special Olympics Inc. and Special Olympics Arizona, including but not limited to:

* 13. Failure to Comply
Please check each item below to verify your acceptance"