Welcome to St. Peter's Health Partners

PLEASE FILL OUT FORM COMPLETELY. INCOMPLETE FORMS WILL NOT BE PROCESSED.

* Application date

Check if you are a:

General Volunteer

Coach

Unified Partner

Bus Driver

GOC/Committee Member

Local/Area Management Team

Other

Please list other:

What kind of volunteering are you interested in? (Please list all)

* First name

Middle name

* Family/Last Name

* DOB

Gender

Race (optional; select all that apply)

Caucasian

African American

Hispanic/Latino

Asian

Native American

Other

* Home Address Line 1

Line 2

* City

* State

* Zip/postal

* E-mail

Home phone

Work phone

Mobile

Fax

Employer and Occupation

Are you already part of a Local Agency?

If yes, which Special Olympics Local Agency?

* How did you hear about Special Olympics Georgia?

Please visit www.SpecialOlympics.org/ProtectiveBehaviors to complete the Protective Behaviors Training. The Protective Behaviors Training must be completed every 3 years in order for you to be considered a Class A Volunteer.

Please list the date the Protective Behaviors Training was completed:

Please answer the following questions honestly:

* 1) Do you use illegal drugs?

* 2) Have you ever been convicted of a criminal offense?

* 3) Have you ever been criminally charged with neglect, abuse or assault?

* 4) Has your driver's license ever been suspended or revoked in any state or other jurisdiction?

If you answered 'Yes' to any of the above questions, please explain below; giving date, charge, state, etc.

*If you answered yes to any of the above questions, it does not automatically mean you will be ineligible to volunteer.

Please note if you have any medical conditions that we need to be aware of. If none, please leave blank.

Emergency Contact

* Name

* Relationship

* Phone Number

Please read completely and check next to each box to acknowlegde you read and understand the below disclosure:

* In consideration of participating in Special Olympics Unified Sports, I represent that I understand the nature of the event and that I (or my child if a minor) am (is) qualified, in good health, and in proper physical condition to participate in Unified Sports events. I fully understand the event involves risks of serious bodily injury which may be caused by my own actions or inactions, by the actions of others participating in the event, or by conditions in which the event takes place. I fully accept and assume all such risks and all responsibility for losses, costs, and/or damages I (and/or my minor child) may incur as a result of my (or my child's if a minor) participation. I acknowledge that at any time that if I (we) feel that the event conditions are unsafe, I, (and/or my minor child) will discontinue participation immediately.

* If during my participation in Special Olympics activities I should need emergency medical treatment and I (or my child if a minor) am (is) not able to give my consent for or make my own arrangements for that treatment because of my injuries, I authorize Special Olympics to take whatever measures are necessary to protect my health and well-being, including, if necessary, hospitalization. I understand the risk of injury and continuing of participation with or after a concussion, and may have to seek medical treatment, possibly waiting 7 days or more and permission from a doctor to play sports again. 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.

* I (or my child if a minor) release, indemnify, covenant not to sue, and hold harmless Special Olympics, its administrators, directors, agents, officers, volunteers, employees, other Unified Sports participants, sponsors, advertisers and if applicable, any owners and lessors of premises on which the activity takes place from all liability, any losses, claims (other than that of the medical accident benefit), demands, costs, or damages that I (or my child if a minor) may incur as a result of participation in Unified Sports events and further agree that if, despite this Release and Waiver of Liability, Assumption of Risk, and Indemnity Agreement, I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any litigation expenses, attorney fees, loss, liability, damage or cost which may incur as a result of such claim.

* 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 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 using my personal information for communications and marketing purposes, including direct digital marketing through email, text message, and social media. I can share my personal information with researchers, such as universities and public health agencies, that are studying intellectual disabilities and the impact of Special Olympics activities, medical professionals in an emergency, and 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. 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.Privacy Policy - Personal information may be used and shared consistent with this form and as further explained in the Special Olympics privacy policy at http://www.specialolympicsga.org/about/special-olympics-georgia-privacy-information/

* SOGA Housing Policy - Special Olympics Georgia (SOGA) usually provides housing for Athletes, Unified Partners and Coaches entered in each State Games. SOGA totals the number of male and female Athletes, Unified Partners and Coaches per agency and assigns room allotments based on those totals. When determining allotted room numbers, SOGA allocates and provides 4 persons of the same gender per room for a Double/Double or King room with a pullout, 2 persons of the same gender per room for a King room and 5 persons of the same gender per room for a Queen/Queen with a pullout. In dorm rooms, SOGA allots one bed per person. Athletes, Unified Partners, Coaches and general volunteers may not share a room with Athletes, Unified Partners, Coaches and general volunteers of the opposite sex.

* In the course of volunteering for Special Olympics, I may be dealing with confidential information and I agree to keep said information in the strictest confidence. The relationship between Special Olympics Georgia and volunteers is an "at will" arrangement, and that it may be terminated at any time without cause by either the volunteer or Special Olympics Georgia. I grant Special Olympics Georgia and Special Olympics, Inc. permission to use my likeness, voice, and words in or on television, radio, film, and on Special Olympics Georgia's and Special Olympics, Inc.'s Website, or in any other form, format or media to promote activities of Special Olympics. I understand that the Protective Behaviors training must be completed every 3 years in order to be considered a Class A volunteer and to participate as a volunteer at any Special Olympics Georgia event. If I am 18 years old or older, I am required by Special Olympics Georgia to submit a background screening every 3 years in order to be considered a Class A volunteer and to participate as a volunteer at any Special Olympics Georgia event. I agree to pay $2.00 for my background screening through Sterling Volunteers, Inc. and I give permission for Special Olympics Georgia to view my background screening.

Your form will not be considered complete until ALL information is received by Special Olympics Georgia.

By electronically signing below, I confirm all information contained in this application is true and complete and correct to the best of my knowledge. I will contact the Special Olympics Georgia office at (770) 414-9390 if any of my information changes. In signing this application, I have read the forgoing information, and I agree to comply with the volunteer or coach code of conduct and all Special Olympics rules and regulations of the organization.