KENTUCKY STATE UNIVERSITY Cooperative Extension Program 4-H Youth Development
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: ___