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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: ___

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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

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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: _____

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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

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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: ___

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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.

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