{ "document_id": 16666, "page": 6, "width_pt": 612, "height_pt": 792, "rotation": 0, "pipeline_version": "paddleocr-vl-1.6+paul-48", "engine": "paddleocr_vl", "source_run_id": 16778, "item_count": 32, "counts_by_type": { "figure": 1, "footer": 2, "form_field": 11, "header": 1, "heading": 3, "list": 2, "list_item": 9, "text": 2, "title": 1 }, "build_ms": 2, "items": [ { "id": "p6.1", "order": 1, "type": "figure", "bbox": { "l": 53.52, "t": 752.88, "r": 169.68, "b": 692.16 }, "text": "", "attrs": { "role": "page_header", "block_label": "header_image" } }, { "id": "p6.2", "order": 2, "type": "header", "bbox": { "l": 184.56, "t": 748.08, "r": 488.64, "b": 716.64 }, "text": "KENTUCKY STATE UNIVERSITY\nCooperative Extension Program 4-H Youth Development", "attrs": { "block_label": "header" }, "level": 2 }, { "id": "p6.3", "order": 3, "type": "title", "bbox": { "l": 185.28, "t": 705.6, "r": 448.08, "b": 667.92 }, "text": "Medical Information and Authorization\nPARENT/GUARDIAN AUTHORIZATION AND RELEASE", "attrs": { "block_label": "doc_title" }, "level": 2 }, { "id": "p6.4", "order": 4, "type": "text", "bbox": { "l": 42.24, "t": 628.56, "r": 312.96, "b": 615.84 }, "text": "PARTICIPANTNAME:___", "children": [ { "id": "p6.4.1", "order": 5, "type": "form_field", "bbox": { "l": 44.0323, "t": 627.5873, "r": 311.0628, "b": 615.5873 }, "text": "", "attrs": { "field_kind": "text", "label": "PARTICIPANTNAME:___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p6.4" } } ] }, { "id": "p6.5", "order": 6, "type": "heading", "bbox": { "l": 40.8, "t": 596.4, "r": 266.4, "b": 582 }, "text": "SECTION 6. MEDICAL AUTHORIZATION", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p6.6", "order": 7, "type": "text", "bbox": { "l": 45.6, "t": 568.08, "r": 550.08, "b": 537.6 }, "text": "I authorize Kentucky State University and YEA staff to provide routine healthcare or first aid, administer medications as listed, and seek emergency medical treatment if necessary." }, { "id": "p6.7", "order": 8, "type": "heading", "bbox": { "l": 46.08, "t": 534.48, "r": 137.28, "b": 522.96 }, "text": "I understand that:", "level": 3 }, { "id": "p6.8", "order": 9, "type": "list", "bbox": { "l": 42.72, "t": 517.696889, "r": 575.52, "b": 312.48 }, "text": "", "attrs": { "item_count": 6 }, "children": [ { "id": "p6.8.1", "order": 10, "type": "list_item", "bbox": { "l": 68.733232, "t": 517.696889, "r": 317.305488, "b": 505.696889 }, "text": "I am responsible for any medical expenses incurred", "marker": "-" }, { "id": "p6.8.2", "order": 11, "type": "list_item", "bbox": { "l": 68.733232, "t": 501.196889, "r": 252.272287, "b": 489.19689 }, "text": "I will be notified in case of emergency", "marker": "-" }, { "id": "p6.8.3", "order": 12, "type": "list_item", "bbox": { "l": 48.342608, "t": 463.696891, "r": 403.965642, "b": 451.696891 }, "text": "Parent/Guardian Name (print): ___", "children": [ { "id": "p6.8.3.1", "order": 13, "type": "form_field", "bbox": { "l": 48.3426, "t": 463.6969, "r": 403.9488, "b": 451.6969 }, "text": "", "attrs": { "field_kind": "text", "label": "Parent/Guardian Name (print): ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p6.8.3" } } ] }, { "id": "p6.8.4", "order": 14, "type": "list_item", "bbox": { "l": 48.342608, "t": 438.196892, "r": 393.295722, "b": 426.196892 }, "text": "Signature: ___", "children": [ { "id": "p6.8.4.1", "order": 15, "type": "form_field", "bbox": { "l": 48.3426, "t": 438.1969, "r": 393.278, "b": 426.1969 }, "text": "", "attrs": { "field_kind": "text", "label": "Signature: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p6.8.4" } } ] }, { "id": "p6.8.5", "order": 16, "type": "list_item", "bbox": { "l": 48.342608, "t": 412.696893, "r": 238.514476, "b": 400.69689400000004 }, "text": "Date: ___", "children": [ { "id": "p6.8.5.1", "order": 17, "type": "form_field", "bbox": { "l": 48.3426, "t": 412.6969, "r": 238.5094, "b": 400.6969 }, "text": "", "attrs": { "field_kind": "text", "label": "Date: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p6.8.5" } } ] }, { "id": "p6.8.6", "order": 18, "type": "list_item", "bbox": { "l": 42.72, "t": 393.12, "r": 575.52, "b": 312.48 }, "text": "___", "attrs": { "bbox_estimated": true }, "children": [ { "id": "p6.8.6.1", "order": 19, "type": "form_field", "bbox": { "l": 46.5142, "t": 359.5969, "r": 572.4028, "b": 347.5969 }, "text": "", "attrs": { "field_kind": "text", "source": "blank_line" } } ] } ] }, { "id": "p6.9", "order": 20, "type": "heading", "bbox": { "l": 35.76, "t": 299.52, "r": 323.52, "b": 282.24 }, "text": "FOR PROGRAM/CAMP STAFF USE ONLY", "attrs": { "block_label": "paragraph_title" }, "level": 3 }, { "id": "p6.10", "order": 21, "type": "list", "bbox": { "l": 41.76, "t": 270.48, "r": 583.44, "b": 139.44 }, "text": "", "attrs": { "item_count": 3 }, "children": [ { "id": "p6.10.1", "order": 22, "type": "list_item", "bbox": { "l": 42, "t": 270.48, "r": 399.36, "b": 256.56 }, "text": "Medications Received By: ___", "children": [ { "id": "p6.10.1.1", "order": 23, "type": "form_field", "bbox": { "l": 44.0323, "t": 269.4929, "r": 397.9729, "b": 257.4929 }, "text": "", "attrs": { "field_kind": "text", "label": "Medications Received By: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p6.10.1" } } ] }, { "id": "p6.10.2", "order": 24, "type": "list_item", "bbox": { "l": 42.72, "t": 247.68, "r": 235.92, "b": 234 }, "text": "Date: ___", "children": [ { "id": "p6.10.2.1", "order": 25, "type": "form_field", "bbox": { "l": 44.0323, "t": 246.9929, "r": 234.199, "b": 234.9929 }, "text": "", "attrs": { "field_kind": "text", "label": "Date: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p6.10.2" } } ] }, { "id": "p6.10.3", "order": 26, "type": "list_item", "bbox": { "l": 41.76, "t": 224.16, "r": 583.44, "b": 139.44 }, "text": "Notes: ___", "children": [ { "id": "p6.10.3.1", "order": 27, "type": "form_field", "bbox": { "l": 44.0323, "t": 224.4929, "r": 580.5777, "b": 212.4929 }, "text": "", "attrs": { "field_kind": "text", "label": "Notes: ___", "source": "blank_line", "label_source": "parent_text", "label_ref": "p6.10.3" } }, { "id": "p6.10.3.2", "order": 28, "type": "form_field", "bbox": { "l": 44.0323, "t": 201.9929, "r": 581.8729, "b": 189.9929 }, "text": "", "attrs": { "field_kind": "text", "source": "blank_line", "label": "Notes: ___", "label_source": "parent_text", "label_ref": "p6.10.3" } }, { "id": "p6.10.3.3", "order": 29, "type": "form_field", "bbox": { "l": 44.0323, "t": 179.4929, "r": 581.8729, "b": 167.4929 }, "text": "", "attrs": { "field_kind": "text", "source": "blank_line", "label": "Notes: ___", "label_source": "parent_text", "label_ref": "p6.10.3" } }, { "id": "p6.10.3.4", "order": 30, "type": "form_field", "bbox": { "l": 44.0323, "t": 156.9929, "r": 581.8729, "b": 144.9929 }, "text": "", "attrs": { "field_kind": "text", "source": "blank_line", "label": "Notes: ___", "label_source": "parent_text", "label_ref": "p6.10.3" } } ] } ] }, { "id": "p6.11", "order": 31, "type": "footer", "bbox": { "l": 158.16, "t": 33.36, "r": 422.16, "b": 22.08 }, "text": "Kentucky State University is an equal opportunity provider.", "attrs": { "block_label": "footer" } }, { "id": "p6.12", "order": 32, "type": "footer", "bbox": { "l": 563.04, "t": 46.32, "r": 571.68, "b": 35.28 }, "text": "6", "attrs": { "block_label": "number" } } ], "excluded_furniture": { "first": [], "last": [] } }