Participant Information Participant Full Name Participant Birth Date (MM/DD/YYYY) Participant Role Athlete Unified partner Coach Volunteer Area/ CountyPlease select... Area 1 (Hudson) Area 2 (Passaic) Area 3 (Sussex, Warren, Morris) Area 4 (Hunterdon) Area 5 (Union , Middlesex) Area 6 (Ocean, Monmouth) Area 7 (Camden, Gloucester, Salem) Area 8 (Atlantic, Cape May, Cumberland) Area 9 (Essex) Area 10 (Somerset) Area 11 (Mercer) Area 12 (Bergen) Area 13 (Burlington) E-mail Phone Phone Type HomeMobile Who is at Higher Risk Of COVID-19? COVID-19 is a new disease and information is changing on who is more likely to get COVID-19 and who is will have more complications. Based on currently available information and clinical expertise, people with intellectual and developmental disabilities may be at higher risk of severe illness resulting in death from COVID-19. In order to participate, you must sign the High Risk Waiver (if applicable) and the COVID-19 Code of Conduct Waiver.Current clinical guidance and information from the U.S. Centers for Disease Control andPrevention (CDC) and World Health Organization (WHO) lists those at high risk for severe illness from COVID-19 as:People 65 years and older. Risk increases with age.People who live in a nursing home or licensed long-term care facilitiesRegardless of age, individuals with underlying conditions, such as the following, are or maybe at increased risk of severe illness from COVID-19:People with chronic lung disease, chronic obstructive pulmonary disease or moderate to severe asthmaPeople who have serious heart conditions (including heart failure, coronary artery disease, congenital heart disease, cardiomyopathy, hypertension)People who are immunocompromised Many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and prolonged use of corticosteroids and other immune weakening medicationsPeople with obesity (body mass index [BMI] of 30 or higher). To calculate BMI, refer to: https://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bmi_calculator/bmi_calculator.htmlPeople with diabetes (Type 1 and 2)People with chronic kidney diseasePeople with liver diseasePeople with dementiaPeople with Down SyndromeThe list may change as evidence is learned. Please review the latest list of conditions that put individuals at increased risk available at the CDC website (https://bit.ly/2VEJcSK)If you are at a high risk, you may be putting yourself at risk when you return to activities with Special Olympics New Jersey. But, you may also put your family and your teammates at risk. If you have these conditions, you should seek additional medical advice prior to returning.If you have been diagnosed with COVID-19, you should consult with a healthcare professional for written medical clearance before returning to Special Olympics in person activities as serious cardiac, respiratory, and neurological issues may develop as a result of COVID-19. High Risk Waiver Are you high risk as outlined above?YesNo You hereby release and agree to hold Special Olympics New Jersey harmless from any and all claims and causes of action for damages, costs, and/or expenses that may arise from any actions or inactions by Special Olympics New Jersey that you believe resulted in injury to you related to COVID-19. You understand that you are discharging Special Olympics New Jersey from any liability or claim that you, your heirs or personal representatives may have against Special Olympics New Jersey for any claim for bodily injury, illness, medical treatment or other damage that may relate to COVID-19. This liability waiver and release extends to Special Olympics New Jersey and its employees, volunteers and representatives. Signature TypeParticipant Signature (Required for adult (age 18 and older) participants, including adult athlete with capacity to sign documents - e.g. the athlete is their own guardian)Parent/ Guardian Signature (Required for participant who is a minor (younger than age 18) or lacks capacity to sign documents.) Participant Signature Required for adult (age 18 and older) participants, including adult athlete with capacity to sign documents. I have read and understand this waiver. If I have questions, I will ask. By signing, I agree to this waiver. Signature (By signing this High Risk Waiver electronically, you agree your electronic signature is the legal equivalent of your manual signature.) Today's Date (MM/DD/YYYY) Parent/ Guardian Signature Required for participant who is a minor (younger than age 18) or lacks capacity to sign documents. I am a parent or guardian of the athlete/participant named above. I have read and understand this waiver and have explained the contents to the participant as appropriate. By signing, I agree to this waiver on my own behalf and on behalf of the participant. Parent/ Guardian Signature (By signing this High Risk Waiver electronically, you agree your electronic signature is the legal equivalent of your manual signature.) Today's Date (MM/DD/YYYY) Relationship COVID-19 Code of Conduct Waiver I understand I could get COVID-19 through sports, training, competition and/or any group activity at Special Olympics New Jersey. I am choosing to participate in sports, competition and/or other Special Olympics New Jersey activities at my own risk. During the time these precautions are needed, I agree to the following to help keep me and my fellow participants safe by checking all of the boxes below. Failure to complete COVID-19 Code of Conduct will result in no in-person participation allowed If I have COVID-19 symptoms, I will stay at home and NOT go to any activities until 7 days after all of my symptoms are over. If I am exposed to COVID-19 and have no symptoms, I can return 14 days after exposure. Special Olympics New Jersey gave me education on Special Olympics New Jersey rules for COVID-19 and who is at high risk. I know that if I have a high risk condition, I have a greater chance that I could get sick or die from COVID-19. If I have a high risk condition, I should not go to Special Olympics New Jersey events in person, until there is little or no COVID-19 in my community. I have reviewed the Who is at Higher Risk document. I understand I would be considered High Risk as outlined in the High Risk Waiver. I understand that I can choose to participate within the parameters Special Olympics New Jersey has outlined in the Return to Activity Plan. I have made an individual risk assessment and have agreed to continuing my participation. I have signed the High Risk Waiver. I know that before or when I get to a Special Olympics New Jersey activity, they will ask me some questions about symptoms and exposure to COVID-19. They may also take my temperature. I will answer truthfully and participate fully. I will keep at least 6 feet from all participants at all times. I will wear a mask at all times while at Special Olympics New Jersey activities. I may not have to wear it during active exercise. I will wash my hands for 20 seconds or use hand sanitizer before any activities. I will wash my hands any time I sneeze, cough, go to the bathroom or get my hands dirty. I will avoid touching my face. I will cover my mouth when I cough or sneeze and immediately wash my hands after. I will not share drinking bottles or towels with other people. I will only share equipment when instructed to. If equipment must be shared, I will only touch the equipment if it is disinfected first. If I get or have had COVID-19, I will not go to any in-person Special Olympics New Jersey events until 14 days after my symptoms end. I will go to my doctor and get written clearance before returning to any sport or fitness activities. I understand that if I do not follow all of these rules, I may not be allowed to participate in Special Olympics New Jersey activities during this time. I HAVE READ ALL OF THIS AGREEMENT OR HAVE HAD IT READ TO ME AND AGREE TO FOLLOW THESE ACTIONS. Failure to complete COVID-19 Code of Conduct will result in no in-person participation allowed. You hereby release and agree to hold Special Olympics New Jersey harmless from any and all claims and causes of action for damages, costs, and/or expenses that may arise from any actions or inactions by Special Olympics New Jersey that you believe resulted in injury to you related to COVID-19. You understand that you are discharging Special Olympics New Jersey from any liability or claim that you, your heirs or personal representatives may have against Special Olympics New Jersey for any claim for bodily injury, illness, medical treatment or other damage that may relate to COVID-19. This liability waiver and release extends to Special Olympics New Jersey and its employees, volunteers and representatives. Signature TypeParticipant Signature (Required for adult (age 18 and older) participants, including adult athlete with capacity to sign documents - e.g. the athlete is their own guardian)Parent/ Guardian Signature (Required for participant who is a minor (younger than age 18) or lacks capacity to sign documents.) Participant Signature Required for adult (age 18 and older) participants, including adult athlete with capacity to sign documents. By signing this, I acknowledge that I have completely read and fully understand the information in this form. Signature (By signing this Code of Conduct Waiver electronically, you agree your electronic signature is the legal equivalent of your manual signature.) Today's Date (MM/DD/YYYY) Parent/ Guardian Signature Required for participant who is a minor (younger than age 18) or lacks capacity to sign documents. I am a parent or guardian of the athlete/participant named above. I have read and understand this form and have explained the contents to the participant as appropriate. By signing, I agree to this form on my own behalf and on behalf of the participant. Parent/ Guardian Signature (By signing this Code of Conduct Waiver electronically, you agree your electronic signature is the legal equivalent of your manual signature.) Today's Date (MM/DD/YYYY) Relationship E-mail Phone Phone Type HomeMobile Return to Activity Homepage
