SHS Medical Release

Medical Release Form for 4-H Youth & Adults

PARTICIPANT INFORMATION

Name: __________________________________________________     County: ________________________________________

Address: ____________________________________________________________________

Name of Paent or Legal Guardian: (YOUTH ONLY): _________________________________________________________

Primary Physician: ____________________________________________________     Phone: ____________________________

Dentist: _______________________________________________________________      Phone: ____________________________

IN CASE OF EMERGENCY

Primary Contact: _____________________________________________________     Phone: ____________________________

Relationship: __________________________________     City: _____________________________________ State: __________

Alternate Contact: _____________________________________________________   Phone: ____________________________

Relationship: __________________________________      City: -____________________________________   State: ________

INSURANCE INFORMATION

Name of Insurance Carrier: __________________________________________________________________________________

Policy Holder Name: _________________________________________________     Policy NO. : _________________________

DATE OF LAST

Tetanus Shot: _____________   Polio Shot: __________   Mumps Shot: __________    Measles Shot: __________    Rubella Shot: __________

MEDICAL INFROMATION: (circle all that apply and explain if necessary)

Stomach or Intestinal problems                                                                       Any allergies to food or plants

Diabetes or hypoglycemia (low blood sugar)                                                 Special diet or food restrictions

Nervous disorder (convulsion, epilepsy, dizziness, ect.)                              Are you currently under a doctor's care?

Respiratory problems                                                                                        Are you currently taking medications?

Heart Disease                                                                                                      Are there any physical restrictions or medical proplems

Any allergies to medication                                                                               that may require special considerations?

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

AUTHORIZATION FOR TREATMENT (Youth only)

I, __________________________________________________________ do herby give permission to _____________________________________________

                  PARENT/GUARDIAN NAME                                                                                                              CHAPERONE NAME

to seek and obtain any medical care necessary for my child _________________________________________________________________________

                                                                                                                                                YOUTH PARTICIPAN NAME

Parent/Guardian Signature: _______________________________________________________________________     Date: __________________________

ALL PARTICIPANTS

To the Best of my knowledge, accurate information has been provided in all areas of this form.

Participant Signature (youth/adult) ________________________________________________________________     Date: __________________________

If Youth: Parent/Guardian Signature _______________________________________________________________    Date: __________________________