KENTUCKY STATE UNIVERSITY Cooperative Extension Program 4-H Youth Development Medical Information and Authorization PARENT/GUARDIAN AUTHORIZATION AND RELEASE
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