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Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE

TO BE COMPLETED BY PROGRAM STAFF:

Program/Event Name: ___

Date(s):___

County/Location: ___

Employee Name: _____ Program Area: _____

SECTION 1. PARTICIPANT & EMERGENCY CONTACT INFORMATION

Participant information

Participant Name: ___

Date of Birth: ___ / ___ / ___ Gender: ☐ M ☐ F

Parent/Guardian Information

Parent/Guardian Name: ___

Primary Phone: _____ Secondary Phone: _____

Email: ___

Home Address: ___

City: _____ State: _____ Zip: _____

ADDITIONAL EMERGENCY CONTACT

Primary Emergency Contact (if different from parent/guardian)

Name: ___

Phone: ___ Alternate Phone: ___

Relationship: ___

SECONDARY EMERGENCY CONTACT

Name: ___

Phone: _____ Alternate Phone: _____

Relationship: ___

PARTICIPANTNAME:___

SECTION 2. MEDICAL INFORMATION

Family Physician: ___

Physician Phone: ___

Health Insurance Carrier: ___

Policy Number: ___

☐ Copy of insurance card attached

Allergies / Medical Conditions

Dietary Considerations or Special Needs

Current Medications

Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE

PARTICIPANTNAME:___

SECTION 3. HEALTH HISTORY (Please check Yes or No)

Hospitalized in the past? ☐ Yes ☐ No

Breathing issues during activity? ☐ Yes ☐ No

Surgery of any kind? ☐ Yes ☐ No

Use of medical equipment? ☐ Yes ☐ No

Currently taking medications? ☐ Yes ☐ No

Vision problems? □ Yes □ No

Allergies (medications, food, insects)? □ Yes □ No

Bone/joint injuries? ☐ Yes ☐ No

Fainted during exercise? ☐ Yes ☐ No

Missing paired organ? □ Yes □ No

Dizziness during or after exercise? □ Yes □ No

Asthma diagnosis? □ Yes □ No

Chest pain during or after exercise? □ Yes □ No

Use of inhaler? □ Yes □ No

High blood pressure? ☐ Yes ☐ No

Diabetes? □ Yes □ No

Heart murmur? □ Yes □ No

Use insulin? □ Yes □ No

Rapid heartbeat episodes? □ Yes □ No

Tobacco use? □ Yes □ No

Family history of heart problems before age 50?

Family history of sickle-cell anemia? □ Yes □ No

□ Yes □ No

Other medical problems? ☐ Yes ☐ No

Skin problems? ☐ Yes ☐ No

Injury in the last year? ☐ Yes ☐ No

Head injury? ☐ Yes ☐ No

Loss of consciousness? □ Yes □ No

Seizures or epilepsy? □ Yes □ No

Nerve injuries? □ Yes □ No

Heat-related illness? ☐ Yes ☐ No

Dizziness in heat? ☐ Yes ☐ No

Explain any “Yes” responses:

___ ___ ___ ___

Additional Information

Can the participant swim? ☐ Yes ☐ No Date of last tetanus shot: _____

PARTICIPANTNAME:___

SECTION 4. MEDICATION ADMINISTRATION PROCEDURES

The 4-H Youth Programs follow a Medication Administration Procedure to protect all participants and staff.

Prescription Medications

• Must be in original containers with proper instructions
• Must be listed on the Medication Form
• Must be labeled with participant name
• Will be stored and administered by authorized staff only
• Daily medication logs will be maintained

Over-the-Counter Medications

• Cannot be administered without parent/guardian permission
• Must be provided and listed on the Medication Form

Emergency Situations

• 911 will be contacted immediately
• Parent/guardian will be notified

Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE

PARTICIPANTNAME:___

SECTION 5. PERMISSION TO ADMINISTER MEDICATIONS

Medication #1

Medication Name: ___

Dosage: ___

Expiration Date: ___ / ___ / ___

Refrigerate: ☐ Yes ☐ No

Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM

Special Instructions: ___

Possible Reactions: ___

Medication #2

Medication Name: ___

Dosage: ___

Expiration Date: ___ / ___ / ___

Refrigerate: ☐ Yes ☐ No

Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM

Special Instructions: ___

Possible Reactions: ___

Medication #3 (if needed)

Medication Name: ___

Dosage: ___

Expiration Date: ___ / ___ / ___

Refrigerate: ☐ Yes ☐ No

Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM

Special Instructions: ___

Possible Reactions: ___

Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE

PARTICIPANTNAME:___

SECTION 6. MEDICAL AUTHORIZATION

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.

• I understand that:
• I am responsible for any medical expenses incurred
• I will be notified in case of emergency

Parent/Guardian Name (print): ___

Signature: ___

Date: ___

___

FOR PROGRAM/CAMP STAFF USE ONLY

Medications Received By: ___

Date: ___

Notes: ___

Kentucky State University is an equal opportunity provider.