ࡱ> E@ bjbj  ||||<<<<h=mYh0?AAAACZC4DXXXXXXXZR']X4EgC"C4E4EX||AAo'YTGTGTG4E|RAAXTG4EXTGHTGHPM|"NA$? K<PEMN =Y0mYM6]`E]$N||||]N3D"UDTGmDD3D3D3DXXd+h/D DGh/  FORMTEXT      Volunteer Special Olympics South Dakota Adult Volunteer & Unified Partner Application FORMTEXT      Volunteer/Unified PartnerThis form is NOT to be completed by minor applicantsAll Special Olympics volunteer applicants (Class A) who have regular, close physical contact with athletes; are in a position of authority or supervision of athletes; are in a position of trust of athletes; and/or handle substantial amounts of cash or other assets of athletes, are subject to mandatory background checks initiated and paid for by SOSD. The information provided on this form will be used to complete said background check. Examples of Class A volunteers includes, but are not limited to: Coaches, Chaperones and Unified Partners. Section 1Volunteers must complete Sections 1 -3. Unified Partners must complete Sections 1 -4. All fields are required.It is imperative we have your full and complete name, i.e. William, not Bill. Christopher, not Chris FORMTEXT       FORMTEXT       FORMTEXT      Full Last Full FirstFull Middle FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Mailing AddressCityStateZip FORMTEXT       Your Date of Birth: FORMTEXT      / FORMTEXT      / FORMTEXT      The Delegation/School You Are Associated WithMonthDayYear FORMTEXT      - FORMTEXT      - FORMTEXT       FORMTEXT      - FORMTEXT      - FORMTEXT       FORMTEXT      Your Social Security NumberYour Drivers License NumberYour Telephone Number Section 21)Do you use illegal drugs? Yes FORMTEXT      No FORMTEXT      2)Have you ever been convicted of a criminal offence? Yes FORMTEXT      No FORMTEXT      3)Have you ever been charged with neglect, abuse or assault? Yes FORMTEXT      No  FORMTEXT      4)Has your driver s license ever been suspended or revoked in any state?Yes FORMTEXT      No  FORMTEXT       Section 3 Section PLEASE READ BEFORE SIGNING: I understand that: The information that I have provided may be verified, and I give permission to Special Olympics to make inquiry of others concerning my suitability to act as a Special Olympics volunteer; 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 and volunteers is an at will arrangement, and it may be terminated at any time without cause by either the volunteer or Special Olympics. I grant Special Olympics permission to use my likeness, voice and words in television, radio, film, or in any form to promote activities of Special Olympics. I have received, read and understand the SOSD Protective Behaviors Policy. I affirm that I have read the above information and that the information I have given is true and complete.Signed: FORMTEXT      Date:  FORMTEXT      In the case of an emergency, who shall we contact? 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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 in participation. I acknowledge that at any time that if I feel that the event conditions are unsafe, I will discontinue participation immediately. I release, indemnify, covenant not to sue, and hold harmless Special Olympics, its administrators, directors, agents, officers, volunteers, employees, and other Unified Sports participants, and sponsors, advertisers, and if applicable, any owners and lessors of premises on which the activity takes place from all liability and losses, claims (other than that of the medical accident benefit), demands, costs, or damages that I 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 Releases, I will indemnify, save, and hold harmless each of the Releases from any litigation expenses, attorney fees, loss, liability, damage or cost which may incur as a result of such claim. I have read and fully understand the provisions of the above release. This application shall remain in effect for three years from the signature date. 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