Memo
To:
From:
Date:
Subject:
Special Olympics Illinois Unified Soccer Coaches
Jen Marcello
January 19, 2016
2016 Chicago Fire Unified Soccer Team
The Chicago Fire Soccer Club has teamed up with Special Olympics Illinois to again create a Chicago Fire
Unified Soccer All StarTeam. This team will represent the Chicago Fire Soccer Club and Special Olympics
Illinois during one home and one away game match. These special games will be held in conjunction with the
official Chicago Fire vs. FC Dallas MLS regular season game on Saturday, July 16 in Dallas TX and Sunday
August 14 at Toyota vs. Orlando City SC. Special Olympics Illinois is asking for your cooperation in nominating
Unified Soccer athletes and partners for selection. Selection of athletes and partners for the Unified Soccer team
will be based upon participation in and skills and behaviors displayed at the Unified Soccer Clinic being held at
The PrivateBank Fire Pitch on February 20, 2016 from 4-6pm.
Rules for Athlete and Partner Nomination / Eligibility:
 Athletes and Partners have previously competed in Unified Soccer
 Athletes are individuals with intellectual disabilities
 Partners are individuals without intellectual disabilities
 Athletes and Partners must be at least 12 years of age and under the age of 22 through August 14, 2016.
 Athletes and Partners can be male or female
 If submitting an application:
o Priority will be given to athlete/partners that are nominated as a pair, however individual
nominations will be accepted.
o Each applicant must complete the application form.
If you have a male or female athlete who meets the qualifications outlined above, please follow the identified
procedures in this memo to ensure all nomination procedures are met in a timely manner.
 Complete the attached athlete/partner Nomination Form. Failure to provide all requested information may
result in the athlete/partner being disqualified for consideration.
 Please ensure the local head coach and the athlete/partner or his/her parent/guardian signs the form
before submitting to Jen Marcello. Jen Marcello will communicate nominee information with Area
Directors.
 Submit the completed form to Jen Marcello by February 15, 2016
 A selection committee will observe each nominated athlete and partner and assist Special Olympics
Illinois in selecting a Chicago Fire Unified Soccer team.
 The Chicago Fire and Special Olympics Illinois will host a training clinic in which athletes will be run
through drills and game play situations. The selection committee will observe and participate in this clinic.
 Special Olympics Illinois staff will inform all selected athletes, partners, alternates, head coaches and
parents/guardians of their status by March 1, 2016. At that time, individuals will then receive detailed
information regarding roles, responsibilities and pertinent deadlines for all team members for the 2016
Chicago Fire Unified Soccer Team.
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Athlete Selection Criteria
Athletes and Partners selected to be a member of the Chicago Fire Unified Soccer team must demonstrate good
sportsmanship and the ability to function well as a part of a team. Athletes and partners must not only be
dedicated to their sport, but must also have the ability to commit extra time to individual training, travel to monthly
training camps and be involved in other Chicago Fire activities as determined by the Chicago Fire and Special
Olympics Illinois. In addition, each athlete and partner must meet all the individual criteria for selection to the
team:
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Athletes and partners must have participated in an accredited Unified Soccer Sports Training
Program. This training must be conducted in regular conditions for the sport. The Training Program is
defined as at least an eight week course as outlined in the Summer Sports Rules;
The athletes and partners must have participated in a Special Olympics Illinois Unified Soccer
Tournament;
The athletes and partners must agree to train and follow the Special Olympics Illinois code of conduct
at all events and trainings;
Each athlete and partner selected must attend all training sessions as outlined by the Chicago Fire
and Special Olympics Illinois. This includes monthly practices starting in March at designated
Chicago Fire facilities.
Athletes and partners will be required to provide their own transportation to and from the trainings and
other scheduled meetings;
Athletes and partners must have a local coach identified to work in coordination with the Chicago Fire
Unified Soccer Team head coach to train the athlete;
Family/legal guardian or Local Program contact must be present at all required meetings and
orientations as outlined by Special Olympics Illinois;
Athletes and partners must be able to answer all questions in the affirmative on the Athlete/Partner
Nomination Form;
Each athlete and partner is subject to pre (Athlete Selection Criteria) and post selection (Chicago Fire
Team Practices) screening conducted by the Special Olympics Illinois;
Athletes and partners must have a valid Illinois Medical Application or Unified Partner form on file with
Special Olympics Illinois.
Athletes and partners must be able to function independently under supervision;
Athletes and partners must be comfortable flying on an airplane;
Athletes and partners must be able to be assigned to a Chicago Fire Unified Soccer Team coach for
the duration of their travel to/from the Game, during the Game, including in the housing site and
competition venue and during the trainings prior to the Game;
Athletes and partners must be able to be out of the state, away from their families and jobs for
approximately a 2-3 day period to attend the Game (exact travel dates will be available at a later
date);
Athletes and partners must be able to independently manage the activities and skills of daily living, i.e.
toileting, showering, personal hygiene, etc.;
An athlete, partner, or the pair may be removed from the team at any time, for failure to adhere to the
principals or fulfill the responsibilities of the criteria as set forth by Special Olympics Illinois and the
Chicago Fire. An athlete, partner or pair may also be removed from the team for health and safety
issues.
NOTE: Non-Team members, i.e. family members, other athletes, local coaches, etc. will not be allowed to
travel or stay with the Chicago Fire Unified Soccer Team during the games..
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SPECIAL OLYMPICS ILLINOIS
2016 Chicago Fire Unified Soccer Team
Athlete/ Partner Nomination Form
(Coaches, please submit to Jen Marcello by February 15, 2016)
Area #______ Agency Name__________________________________________________________
Please print or type all sections. All sections must be completed.
PART A – ATHLETE/PARTNER INFORMATION
Individual Being Nominated as (Please Circle): ATHLETE
First Name
PARTNER
Last Name
Gender (Please Circle)
MALE
FEMALE
Being Nominated with Athlete/Partner: ____________________________________________________
Mailing Address
City
State
Home Telephone
(
Postal Code
)
E-Mail Address
@
Place of Employment
Age
Date of Birth
What is your primary language?
Do you speak a language, other than English, fluently?
If yes, please list the language(s)
YES
NO
PART B – PARENT/LEGAL GUARDIAN/OFFICIAL CONTACT INFORMATION
Is the athlete / partner their own legal guardian?
YES NO
Parent/Legal Guardian
First Name
Last Name
Mailing Address
City
State
Home Telephone
(
)
Work Telephone
(
)
Mobile Telephone
(
Postal Code
)
E-Mail Address
@
3
Official Contact Person (if different from above)
First Name
Last Name
Mailing Address
City
State
Home Telephone
(
)
Work Telephone
(
)
Mobile Telephone
(
Postal Code
)
E-Mail Address
@
Relationship to the athlete
PART C – LOCAL COACH CONTACT INFORMATION
.
First Name
Last Name
Mailing Address
City
State
Home Telephone
(
)
Work Telephone
(
)
Mobile Telephone
(
Postal Code
)
E-Mail Address
@
4
PART D – ATHLETE’S / PARTNER’S SPORTS BACKGROUND
Please list all positions this athlete / partner plays in the sport of Unified Soccer:
Does the athlete have a current “Application for Participation in Special Olympics” Medical and Parent Release
form on file with Special Olympics Illinois?
YES
NO
If yes, what is the expiration date of the medical?
Does the partner have a current “Unified Sports Application for Participation” and “Class A Volunteer Form” on
file with Special Olympics Illinois?
YES
NO
Is the athlete / partner willing and able to commit to an intensive training program as prescribed by your local and
Chicago Fire Unified Soccer coach?
YES
NO
Can the athlete / partner attend monthly practices from April- August that will require them to be away from
home/work? YES
NO
Is the athlete / partner prepared and capable of spending days away from home and work?
YES
NO
PART E – ATHLETE/PARTNER INVENTORY
A current coach or legal guardian who has traveled overnight with the athlete/partner must fill-in this section.
Physical (circle appropriate description):
Strength:
weak
average
powerful for age
Speed:
slow
average
quick
Coordination:
poor
average
good
General fitness:
poor
average
good
Can athlete swim: YES
NO
Toileting (Check all that apply):
Not toilet trained yet
Wets the bed
Has few accidents
Goes to bathroom alone
Cleans self independently
a.
Self-help Skills (ONLY check skills done without adult supervision/assistance)
Mealtime Skills
Grooming Skills
Feeds self mostly with fingers
Can wash and dry face and hands
Feeds self with spoon
Can comb/brush hair
Feeds self with fork and spoon
Can brush teeth
Feeds self with fork and spoon and can use knife
Can shower and bathe self
Can serve food to self and clear dishes
Can adjust water temperature in bath
b.
Dressing skills (check all that apply)
How long does the athlete take to groom & dress each morning (number of minutes)?
Can dress and undress self
Can dress and undress self with minimal assistance
Cannot dress and undress self
5
c.
Behavior Problems (check all that apply)
Temper tantrums
Hits others unprovoked
Throws objects
Pulls hair
Bites others
Teases others
Runs away
Twirls objects
Gets homesick
Other
Bites self
Bangs head/back
Eats foreign objects
Overly fearful
Aloof from others
Cries often
Doesn’t follow directions
Overly dependent on adults
Doesn’t function well in a group
None Apply
__________________________________________________________________________________
Please list methods for resolving behavior difficulties (e.g. praise, games, sitting quietly, privileges (be specific)
Can the athlete / partner relate to an unfamiliar coach?
If no, please explain
PART F – MEDICAL OVERVIEW
Please check all that apply:
Seizures
Broken Bones
YES
NO
Diabetes
Hepatitis
Glasses/Contacts
Allergies*
Recent Surgery*
*Please explain the type of surgery and/or the specific
allergies______________________________________________
Does the athlete have Down syndrome?
YES
NO
If yes, has athlete had an x-ray to evaluate Atlanto-axial instability?
If yes, was the x-ray positive for Atlanto-axial instability?
YES
YES
NO
NO
Does the athlete / partner take any medications? YES
NO
If yes, please list (attach an additional sheet if necessary):
Medication Name
Dosage
Date Prescribed
Times per day
________________________________________________________________________________________
Is the athlete / partner susceptible to colds, infections, etc.?
If yes, please explain
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YES
NO
FEMALES ONLY:
Have females ever menstruated?
If so, is her cycle normal?
YES
YES
NO
NO
PART G – TRAVEL EXPERIENCE
Has the athlete / partner ever traveled by bus?
YES
NO
Has the athlete / partner ever traveled by airplane?
YES
NO
Has the athlete / partner ever traveled by train?
YES
NO
Is the athlete / partner claustrophobic?
YES
NO
Does the athlete / partner experience discomfort while traveling (motion sickness, homesickness, etc.)? YES
NO
If yes, please explain
Has the athlete / partner taken a long trip away from home without a family member/legal guardian present?
YES NO
PART H – ADDITIONAL COMMENTS ABOUT / FROM THE ATHETE / PARTNER
Please feel free to share additional information you feel would be helpful for coaches who may be chaperoning
this athlete / partner.
PART I – ATHLETE / PARTNER REFERENCES
Please list three references including the athlete’s most recent sport coach in the sport that the athlete / partner
is hoping to compete. References may be contacted to enhance background information about the individual.
Sport Coach Reference (non-family member)
First Name
Last Name
Mailing Address
City
State
Home Telephone
(
)
E-Mail Address
@
Number of years as athlete’s coach
Postal Code
Other References (non-family member)
First Name
Mailing Address
City
Home Telephone
(
)
E-Mail Address
How does the athlete know this person?
Postal Code
First Name
Mailing Address
City
Home Telephone
(
)
E-Mail Address
How does the athlete know this person?
Last Name
State
@
Last Name
State
Postal Code
@
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PART J – SIGNATURE OF AGREEMENT
The information presented in this application is true and accurate to the best of my knowledge.
Signature of Athlete / Partner
Date
Signature of Parent / Guardian
Date
Signature of Person Completing the Form (if different from above)
Date
Return this form by February 15, 2016 to:
Jennifer Marcello
500 Waters Edge Suite 100
Lombard, IL 60148
[email protected]
FOR SPECIAL OLYMPICS ILLINOIS STAFF USE ONLY
Additional Feedback
Comments
Date Received _______________
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