Alabama Cooperative Extension System

Alabama Cooperative Extension System

4-H Youth Development Program

Youth Health Information and Parental Release

Name of Youth Participant:

Home Address:

(Street or Post Office Box No.)

(City)

(State)

(Zip)

Gender:

FORT CLOVER – 4-H CENTER - May 7 – 9, 2004

I hereby certify that my child is in good health and can participate in the above named CES/4-H program or function and may travel as necessary to and from events and activities under appropriate supervision and guidance by Cooperative Extension personnel and volunteer leaders. While my child is involved in the stated programs and activities, I HEREBY AUTHORIZE THE ADULT VOLUNTEER LEADER OR STAFF MEMBER, or in his/her absence or disability, any adult accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING MEDICAL TREATMENT FOR SAID MINOR: Any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician or any X-ray examination, anesthetic, dental or surgical diagnosis or treatment, & care to be rendered by a licensed dentist. This authorization shall remain effective until my child completes his/her activities unless sooner revoked in writing. I understand that as a parent/legal guardian, I will be responsible for the cost of any service/treatment incurred not covered by CES/4-H Youth Accident Insurance when it is provided. See local extension staff regarding accident insurance.

I further acknowledge that injuries or loss can result from participation in CES/4-H Youth programs and assume all risk of injury, loss of life and loss or damage to property, arising out of my child's participation in these programs. I therefore release the Alabama 4-H Foundation; Auburn University, its Board of Trustees, Faculty and Staff; the Alabama Cooperative Extension System including Alabama A&M University, its Board of Trustees, Faculty and Staff; and the Alabama 4-H Center and its employees from all liability as to any right of action that may accrue to myself, my child. his/her heirs or representatives, for any such injuries or loss, including but not limited to, any claim arising out of any negligence, condition of the premises at which the activity is held, or the conduct of any person in connection with the preparation for supervision of, or conduct of any activity, that may be suffered while being transported or engaged in this activity. Should there be any changes in the status of parent/legal guardian or health information, it will be my responsibility to keep the County Extension Office informed or provided with an updated form.

AUTHORIZATION, CONSENT AND RELEASE
Date	Signature of Parent/Legal Guardian		Emergency Phone DAY


Mailing Address		Zip	Emergency Phone NIGHT
PLEASE COMPLETE THE HEALTH HISTORY INFORMATION ON THE REVERSE SIDE.
The information entered on this form is collected under authority of the Smith-Lever Act Submission of the medical data is voluntary. However, a signature is required on the signature line above. Failure to provide the medical information and authorization may result in our inability to provide needed medical treatment. You have the right to review ACES records containing personal information about you/your child as necessary.

Programs provided in furtherance of Cooperative Extension work in agriculture and home economics, Acts of May 8 and June 30, 1914, and other related acts, in cooperation with the U.S. Department of Agriculture. The Alabama Cooperative Extension System (Alabama A&M University and Auburn University) offers educational programs, materials, and equal opportunity employment to all people without regard to race, color, national origin, religion, sex, age, veteran status, or disability.

HEALTH HISTORY INFORMATION

(This information is confidential and will be used only in case of emergency.)

Name of Youth Participant:

Social Security Number:

Date of Birth:

(Optional)

Month Day Year

Is your child subject to:

Yes

Does your child have or has he or

she ever had:

Yes

Colds

Heart Trouble

Sore Throat

Asthma

Fainting Spells

Lung Trouble

Bronchitis

Sinus Trouble

Convulsions

Hernia (rupture)

Cramps

Appendicitis

Allergies

Has appendix been removed?

Is the child currently under any type of medical treatment?

Is there any history of behavior disorders or emotional disturbances, such as difficulties in

relationships with authority figures or peers, or abnormally severe moodiness?

In the event over the counter medication is needed, do you give your permission to administer such?

If so, what medications do you prefer given?

Attach addendum medical form if necessary!

Has the child been under psychiatric treatment within the past three years?

Date of child’s last Tetanus Vaccination:

Month/Day/Yr

Please identify child’s allergies, including allergies to food, medications, or drug reactions you know about:

Please list any physical disabilities or disorders that may limit your child’s activities at this 4-H function, such as eyesight, hearing, speech, paralysis, diabetes, ulcer, etc.

Please list all medications that your child is presently taking:

Name of Medication

Dosage

Times Taken

Remarks and any special instructions. Please explain "Yes" answers on this page.

Attach this form to the Youth Health Information & release form for this child.

Medication will not be given to your child without your written permission during the program specified within the accompanying Health Information and Release Form. Any prescription drug(s) sent to this program must be in its original container and clearly labeled with the child's name, the name of the drug(s), and directions for administering the drug(s). No medication will be given against instructions printed on the label. If it is absolutely necessary for your child to be given medication while attending this program, please complete the following information:

Child's Name

Medication Prescription No(s).

Name(s) of Medication(s)

I give my permission for administering of the following over the counter medications as deemed necessary (check those that apply). Dosages will be administered according to directions on the bottles unless a physician directs otherwise:

Ailment

Medication

Ailment

Medication

Headache

Tylenol

Diarrhea

Immodium AD

Upset Stomach

Pepto-Bismol

Menstrual Cramps

Ibuprophen

Poison Ivy

Calamine Lotion/CortAid

Others:

To be completed by parent

Known allergies to medications, insect bites, etc.

Please give my child the above referenced medication at the time (s) and in the amount (s) indicated below.

Time of last dosage at home:

Time of dosage to be given at program:

Amount of medication to be given with each dosage:

Signature of Parent/Guardian

Date

To be completed by Staff:

Date and Time Medication Given

Administered By

Other Instructions:

NOTE: A copy of this form should be kept in the student's file and a copy sent home to the child's parent.