[ { "page": 1, "items": [ { "page": 1, "type": "TITLE", "location": { "l": 179.52, "t": 709.44, "r": 442.32, "b": 678.24 }, "text": "Medical Information and Authorization\nPARENT/GUARDIAN AUTHORIZATION AND RELEASE", "reading_order": 0, "level": 1 }, { "page": 1, "type": "TITLE", "location": { "l": 30.96, "t": 663.84, "r": 201.12, "b": 652.8 }, "text": "TO BE COMPLETED BY PROGRAM STAFF:", "reading_order": 1, "level": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 30.96, "t": 644.4, "r": 574.32, "b": 631.92 }, "text": "Program/Event Name: ___", "reading_order": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 31.68, "t": 625.92, "r": 271.92, "b": 613.2 }, "text": "Date(s):___", "reading_order": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 32.88, "t": 625.92, "r": 573.12, "b": 613.44 }, "text": "County/Location: ___", "reading_order": 4 }, { "page": 1, "type": "TEXT", "location": { "l": 34.08, "t": 607.2, "r": 578.64, "b": 593.76 }, "text": "Employee Name: _____ Program Area: _____", "reading_order": 5 }, { "page": 1, "type": "TITLE", "location": { "l": 31.68, "t": 556.32, "r": 414.48, "b": 542.16 }, "text": "SECTION 1. PARTICIPANT & EMERGENCY CONTACT INFORMATION", "reading_order": 6, "level": 2 }, { "page": 1, "type": "TITLE", "location": { "l": 31.92, "t": 525.84, "r": 161.76, "b": 512.64 }, "text": "Participant information", "reading_order": 7, "level": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 31.44, "t": 506.64, "r": 388.8, "b": 493.92 }, "text": "Participant Name: ___", "reading_order": 8 }, { "page": 1, "type": "TEXT", "location": { "l": 32.4, "t": 491.04, "r": 291.36, "b": 477.84 }, "text": "Date of Birth: ___ / ___ / ___ Gender: ☐ M ☐ F", "reading_order": 9 }, { "page": 1, "type": "TITLE", "location": { "l": 31.68, "t": 450.48, "r": 180.96, "b": 437.76 }, "text": "Parent/Guardian Information", "reading_order": 10, "level": 3 }, { "page": 1, "type": "TEXT", "location": { "l": 31.68, "t": 430.32, "r": 393.12, "b": 417.36 }, "text": "Parent/Guardian Name: ___", "reading_order": 11 }, { "page": 1, "type": "TEXT", "location": { "l": 31.44, "t": 411.6, "r": 469.68, "b": 398.4 }, "text": "Primary Phone: _____ Secondary Phone: _____", "reading_order": 12 }, { "page": 1, "type": "TEXT", "location": { "l": 31.68, "t": 391.68, "r": 396.96, "b": 378.72 }, "text": "Email: ___", "reading_order": 13 }, { "page": 1, "type": "TEXT", "location": { "l": 31.68, "t": 372.24, "r": 393.6, "b": 358.8 }, "text": "Home Address: ___", "reading_order": 14 }, { "page": 1, "type": "TEXT", "location": { "l": 32.16, "t": 352.32, "r": 386.16, "b": 338.88 }, "text": "City: _____ State: _____ Zip: _____", "reading_order": 15 }, { "page": 1, "type": "TITLE", "location": { "l": 35.52, "t": 295.44, "r": 231.6, "b": 282.48 }, "text": "ADDITIONAL EMERGENCY CONTACT", "reading_order": 16, "level": 3 }, { "page": 1, "type": "TITLE", "location": { "l": 35.04, "t": 254.88, "r": 349.92, "b": 240.96 }, "text": "Primary Emergency Contact (if different from parent/guardian)", "reading_order": 17, "level": 2 }, { "page": 1, "type": "TEXT", "location": { "l": 35.28, "t": 234, "r": 324.48, "b": 221.52 }, "text": "Name: ___", "reading_order": 18 }, { "page": 1, "type": "TEXT", "location": { "l": 35.28, "t": 215.52, "r": 426.24, "b": 201.84 }, "text": "Phone: ___ Alternate Phone: ___", "reading_order": 19 }, { "page": 1, "type": "TEXT", "location": { "l": 35.52, "t": 195.6, "r": 319.92, "b": 182.4 }, "text": "Relationship: ___", "reading_order": 20 }, { "page": 1, "type": "TEXT", "location": { "l": 35.28, "t": 176.64, "r": 215.04, "b": 163.92 }, "text": "SECONDARY EMERGENCY CONTACT", "reading_order": 21 }, { "page": 1, "type": "TEXT", "location": { "l": 35.04, "t": 156.48, "r": 324.72, "b": 144 }, "text": "Name: ___", "reading_order": 22 }, { "page": 1, "type": "TEXT", "location": { "l": 35.28, "t": 137.52, "r": 426.48, "b": 124.32 }, "text": "Phone: _____ Alternate Phone: _____", "reading_order": 23 }, { "page": 1, "type": "TEXT", "location": { "l": 35.52, "t": 117.84, "r": 319.92, "b": 104.4 }, "text": "Relationship: ___", "reading_order": 24 } ] }, { "page": 2, "items": [ { "page": 2, "type": "TEXT", "location": { "l": 34.8, "t": 654.72, "r": 304.8, "b": 641.28 }, "text": "PARTICIPANTNAME:___", "reading_order": 0 }, { "page": 2, "type": "TITLE", "location": { "l": 34.56, "t": 609.6, "r": 247.44, "b": 595.2 }, "text": "SECTION 2. MEDICAL INFORMATION", "reading_order": 1, "level": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 45.12, "t": 577.44, "r": 396.96, "b": 563.52 }, "text": "Family Physician: ___", "reading_order": 2 }, { "page": 2, "type": "TEXT", "location": { "l": 45.36, "t": 556.8, "r": 396.24, "b": 542.88 }, "text": "Physician Phone: ___", "reading_order": 3 }, { "page": 2, "type": "TEXT", "location": { "l": 44.88, "t": 535.92, "r": 395.76, "b": 522 }, "text": "Health Insurance Carrier: ___", "reading_order": 4 }, { "page": 2, "type": "TEXT", "location": { "l": 45.36, "t": 515.28, "r": 400.56, "b": 501.12 }, "text": "Policy Number: ___", "reading_order": 5 }, { "page": 2, "type": "TEXT", "location": { "l": 45.36, "t": 493.92, "r": 215.52, "b": 480.72 }, "text": "☐ Copy of insurance card attached", "reading_order": 6 }, { "page": 2, "type": "TITLE", "location": { "l": 45.36, "t": 446.88, "r": 210.96, "b": 432 }, "text": "Allergies / Medical Conditions", "reading_order": 7, "level": 2 }, { "page": 2, "type": "FIGURE", "location": { "l": 46.32, "t": 418.32, "r": 543.84, "b": 307.2 }, "text": "", "reading_order": 8 }, { "page": 2, "type": "TEXT", "location": { "l": 45.84, "t": 290.4, "r": 264, "b": 275.52 }, "text": "Dietary Considerations or Special Needs", "reading_order": 9 }, { "page": 2, "type": "FIGURE", "location": { "l": 46.56, "t": 267.12, "r": 542.64, "b": 155.76 }, "text": "", "reading_order": 10 }, { "page": 2, "type": "TEXT", "location": { "l": 46.56, "t": 149.04, "r": 159.36, "b": 135.12 }, "text": "Current Medications", "reading_order": 11 }, { "page": 2, "type": "FIGURE", "location": { "l": 46.08, "t": 132.96, "r": 540.24, "b": 23.52 }, "text": "", "reading_order": 12 } ] }, { "page": 3, "items": [ { "page": 3, "type": "TITLE", "location": { "l": 171.84, "t": 706.56, "r": 436.32, "b": 665.04 }, "text": "Medical Information and Authorization\nPARENT/GUARDIAN AUTHORIZATION AND RELEASE", "reading_order": 0, "level": 1 }, { "page": 3, "type": "TEXT", "location": { "l": 40.8, "t": 634.56, "r": 311.52, "b": 621.6 }, "text": "PARTICIPANTNAME:___", "reading_order": 1 }, { "page": 3, "type": "TITLE", "location": { "l": 40.56, "t": 583.44, "r": 344.64, "b": 568.8 }, "text": "SECTION 3. HEALTH HISTORY (Please check Yes or No)", "reading_order": 2, "level": 2 }, { "page": 3, "type": "TEXT", "location": { "l": 38.16, "t": 547.44, "r": 216.48, "b": 534.24 }, "text": "Hospitalized in the past? ☐ Yes ☐ No", "reading_order": 3 }, { "page": 3, "type": "TEXT", "location": { "l": 328.08, "t": 539.52, "r": 544.32, "b": 525.36 }, "text": "Breathing issues during activity? ☐ Yes ☐ No", "reading_order": 4 }, { "page": 3, "type": "TEXT", "location": { "l": 38.16, "t": 526.32, "r": 196.56, "b": 513.12 }, "text": "Surgery of any kind? ☐ Yes ☐ No", "reading_order": 5 }, { "page": 3, "type": "TEXT", "location": { "l": 328.56, "t": 518.4, "r": 522.24, "b": 504.48 }, "text": "Use of medical equipment? ☐ Yes ☐ No", "reading_order": 6 }, { "page": 3, "type": "TEXT", "location": { "l": 38.16, "t": 505.44, "r": 243.12, "b": 491.76 }, "text": "Currently taking medications? ☐ Yes ☐ No", "reading_order": 7 }, { "page": 3, "type": "TEXT", "location": { "l": 328.8, "t": 497.52, "r": 472.08, "b": 483.36 }, "text": "Vision problems? □ Yes □ No", "reading_order": 8 }, { "page": 3, "type": "TEXT", "location": { "l": 38.16, "t": 485.04, "r": 281.04, "b": 470.64 }, "text": "Allergies (medications, food, insects)? □ Yes □ No", "reading_order": 9 }, { "page": 3, "type": "TEXT", "location": { "l": 328.56, "t": 476.4, "r": 483.84, "b": 462.48 }, "text": "Bone/joint injuries? ☐ Yes ☐ No", "reading_order": 10 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 463.68, "r": 215.52, "b": 450.24 }, "text": "Fainted during exercise? ☐ Yes ☐ No", "reading_order": 11 }, { "page": 3, "type": "TEXT", "location": { "l": 328.8, "t": 455.52, "r": 494.88, "b": 441.36 }, "text": "Missing paired organ? □ Yes □ No", "reading_order": 12 }, { "page": 3, "type": "TEXT", "location": { "l": 38.16, "t": 442.8, "r": 262.56, "b": 429.36 }, "text": "Dizziness during or after exercise? □ Yes □ No", "reading_order": 13 }, { "page": 3, "type": "TEXT", "location": { "l": 328.56, "t": 434.4, "r": 479.04, "b": 420.24 }, "text": "Asthma diagnosis? □ Yes □ No", "reading_order": 14 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 421.44, "r": 269.28, "b": 408 }, "text": "Chest pain during or after exercise? □ Yes □ No", "reading_order": 15 }, { "page": 3, "type": "TEXT", "location": { "l": 328.8, "t": 413.52, "r": 461.52, "b": 399.36 }, "text": "Use of inhaler? □ Yes □ No", "reading_order": 16 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 400.56, "r": 200.88, "b": 386.88 }, "text": "High blood pressure? ☐ Yes ☐ No", "reading_order": 17 }, { "page": 3, "type": "TEXT", "location": { "l": 329.04, "t": 392.4, "r": 436.56, "b": 378.72 }, "text": "Diabetes? □ Yes □ No", "reading_order": 18 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 379.44, "r": 173.28, "b": 366.24 }, "text": "Heart murmur? □ Yes □ No", "reading_order": 19 }, { "page": 3, "type": "TEXT", "location": { "l": 329.04, "t": 371.52, "r": 446.64, "b": 357.84 }, "text": "Use insulin? □ Yes □ No", "reading_order": 20 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 358.56, "r": 226.8, "b": 345.12 }, "text": "Rapid heartbeat episodes? □ Yes □ No", "reading_order": 21 }, { "page": 3, "type": "TEXT", "location": { "l": 329.04, "t": 350.16, "r": 452.88, "b": 336.48 }, "text": "Tobacco use? □ Yes □ No", "reading_order": 22 }, { "page": 3, "type": "TEXT", "location": { "l": 37.92, "t": 337.92, "r": 275.52, "b": 323.52 }, "text": "Family history of heart problems before age 50?", "reading_order": 23 }, { "page": 3, "type": "TEXT", "location": { "l": 328.8, "t": 329.52, "r": 561.84, "b": 315.12 }, "text": "Family history of sickle-cell anemia? □ Yes □ No", "reading_order": 24 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 316.32, "r": 94.56, "b": 303.36 }, "text": "□ Yes □ No", "reading_order": 25 }, { "page": 3, "type": "TEXT", "location": { "l": 328.56, "t": 308.64, "r": 512.16, "b": 294.48 }, "text": "Other medical problems? ☐ Yes ☐ No", "reading_order": 26 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 295.2, "r": 171.84, "b": 281.76 }, "text": "Skin problems? ☐ Yes ☐ No", "reading_order": 27 }, { "page": 3, "type": "TEXT", "location": { "l": 328.8, "t": 287.52, "r": 496.32, "b": 272.88 }, "text": "Injury in the last year? ☐ Yes ☐ No", "reading_order": 28 }, { "page": 3, "type": "TEXT", "location": { "l": 38.88, "t": 274.8, "r": 159.36, "b": 261.36 }, "text": "Head injury? ☐ Yes ☐ No", "reading_order": 29 }, { "page": 3, "type": "TEXT", "location": { "l": 38.16, "t": 253.44, "r": 208.32, "b": 240.24 }, "text": "Loss of consciousness? □ Yes □ No", "reading_order": 30 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 232.56, "r": 198.96, "b": 219.36 }, "text": "Seizures or epilepsy? □ Yes □ No", "reading_order": 31 }, { "page": 3, "type": "TEXT", "location": { "l": 38.64, "t": 211.44, "r": 171.12, "b": 198 }, "text": "Nerve injuries? □ Yes □ No", "reading_order": 32 }, { "page": 3, "type": "TEXT", "location": { "l": 38.16, "t": 190.8, "r": 196.8, "b": 176.88 }, "text": "Heat-related illness? ☐ Yes ☐ No", "reading_order": 33 }, { "page": 3, "type": "TEXT", "location": { "l": 38.4, "t": 169.68, "r": 184.08, "b": 156.24 }, "text": "Dizziness in heat? ☐ Yes ☐ No", "reading_order": 34 }, { "page": 3, "type": "TEXT", "location": { "l": 325.44, "t": 230.88, "r": 470.4, "b": 216.72 }, "text": "Explain any “Yes” responses:", "reading_order": 35 }, { "page": 3, "type": "TEXT", "location": { "l": 323.76, "t": 204, "r": 537.6, "b": 118.32 }, "text": "___\n___\n___\n___", "reading_order": 36 }, { "page": 3, "type": "TITLE", "location": { "l": 46.8, "t": 110.88, "r": 184.32, "b": 96.48 }, "text": "Additional Information", "reading_order": 37, "level": 2 }, { "page": 3, "type": "TEXT", "location": { "l": 46.8, "t": 91.44, "r": 329.52, "b": 61.44 }, "text": "Can the participant swim? ☐ Yes ☐ No\nDate of last tetanus shot: _____", "reading_order": 38 } ] }, { "page": 4, "items": [ { "page": 4, "type": "TEXT", "location": { "l": 53.04, "t": 643.92, "r": 324.24, "b": 630.96 }, "text": "PARTICIPANTNAME:___", "reading_order": 0 }, { "page": 4, "type": "TITLE", "location": { "l": 44.4, "t": 581.76, "r": 381.12, "b": 567.6 }, "text": "SECTION 4. MEDICATION ADMINISTRATION PROCEDURES", "reading_order": 1, "level": 2 }, { "page": 4, "type": "TEXT", "location": { "l": 45.6, "t": 552.72, "r": 565.92, "b": 538.8 }, "text": "The 4-H Youth Programs follow a Medication Administration Procedure to protect all participants and staff.", "reading_order": 2 }, { "page": 4, "type": "TITLE", "location": { "l": 45.36, "t": 525.84, "r": 174, "b": 512.88 }, "text": "Prescription Medications", "reading_order": 3, "level": 3 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 53.52, "t": 507.6, "r": 334.8, "b": 494.4 }, "text": "Must be in original containers with proper instructions", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 4 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 54.24, "t": 486.48, "r": 259.2, "b": 474 }, "text": "Must be listed on the Medication Form", "marker": "-", "list_id": "L1", "level": 0, "reading_order": 5 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 53.52, "t": 465.36, "r": 258.48, "b": 451.92 }, "text": "Must be labeled with participant name", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 6 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 53.52, "t": 444.96, "r": 342.96, "b": 431.04 }, "text": "Will be stored and administered by authorized staff only", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 7 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 53.52, "t": 423.6, "r": 265.92, "b": 410.16 }, "text": "Daily medication logs will be maintained", "marker": "•", "list_id": "L1", "level": 0, "reading_order": 8 }, { "page": 4, "type": "TITLE", "location": { "l": 45.6, "t": 388.32, "r": 201.12, "b": 375.84 }, "text": "Over-the-Counter Medications", "reading_order": 9, "level": 3 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 53.52, "t": 368.4, "r": 366.24, "b": 354.96 }, "text": "Cannot be administered without parent/guardian permission", "marker": "•", "list_id": "L2", "level": 0, "reading_order": 10 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 54, "t": 347.52, "r": 326.64, "b": 334.08 }, "text": "Must be provided and listed on the Medication Form", "marker": "-", "list_id": "L2", "level": 0, "reading_order": 11 }, { "page": 4, "type": "TITLE", "location": { "l": 45.6, "t": 302.64, "r": 156.48, "b": 289.68 }, "text": "Emergency Situations", "reading_order": 12, "level": 3 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 53.76, "t": 282.96, "r": 236.88, "b": 269.52 }, "text": "911 will be contacted immediately", "marker": "•", "list_id": "L3", "level": 0, "reading_order": 13 }, { "page": 4, "type": "LIST_ITEM", "location": { "l": 54, "t": 262.32, "r": 224.64, "b": 248.64 }, "text": "Parent/guardian will be notified", "marker": "•", "list_id": "L3", "level": 0, "reading_order": 14 } ] }, { "page": 5, "items": [ { "page": 5, "type": "TITLE", "location": { "l": 185.04, "t": 705.12, "r": 447.84, "b": 665.76 }, "text": "Medical Information and Authorization\nPARENT/GUARDIAN AUTHORIZATION AND RELEASE", "reading_order": 0, "level": 1 }, { "page": 5, "type": "TEXT", "location": { "l": 40.32, "t": 629.28, "r": 311.76, "b": 615.36 }, "text": "PARTICIPANTNAME:___", "reading_order": 1 }, { "page": 5, "type": "TITLE", "location": { "l": 37.68, "t": 594.48, "r": 365.04, "b": 579.84 }, "text": "SECTION 5. PERMISSION TO ADMINISTER MEDICATIONS", "reading_order": 2, "level": 2 }, { "page": 5, "type": "TITLE", "location": { "l": 38.64, "t": 564.72, "r": 113.52, "b": 551.28 }, "text": "Medication #1", "reading_order": 3, "level": 3 }, { "page": 5, "type": "TEXT", "location": { "l": 38.88, "t": 545.04, "r": 399.12, "b": 530.88 }, "text": "Medication Name: ___", "reading_order": 4 }, { "page": 5, "type": "TEXT", "location": { "l": 38.88, "t": 523.92, "r": 400.8, "b": 510 }, "text": "Dosage: ___", "reading_order": 5 }, { "page": 5, "type": "TEXT", "location": { "l": 39.12, "t": 503.28, "r": 227.28, "b": 488.4 }, "text": "Expiration Date: ___ / ___ / ___", "reading_order": 6 }, { "page": 5, "type": "TEXT", "location": { "l": 39.12, "t": 481.92, "r": 155.04, "b": 468 }, "text": "Refrigerate: ☐ Yes ☐ No", "reading_order": 7 }, { "page": 5, "type": "TEXT", "location": { "l": 39.12, "t": 461.28, "r": 345.36, "b": 446.88 }, "text": "Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM", "reading_order": 8 }, { "page": 5, "type": "TEXT", "location": { "l": 38.88, "t": 439.92, "r": 564.72, "b": 425.76 }, "text": "Special Instructions: ___", "reading_order": 9 }, { "page": 5, "type": "TEXT", "location": { "l": 38.64, "t": 419.28, "r": 566.88, "b": 404.88 }, "text": "Possible Reactions: ___", "reading_order": 10 }, { "page": 5, "type": "TITLE", "location": { "l": 37.2, "t": 383.76, "r": 112.08, "b": 370.56 }, "text": "Medication #2", "reading_order": 11, "level": 3 }, { "page": 5, "type": "TEXT", "location": { "l": 36.96, "t": 364.08, "r": 397.44, "b": 349.44 }, "text": "Medication Name: ___", "reading_order": 12 }, { "page": 5, "type": "TEXT", "location": { "l": 37.44, "t": 342.96, "r": 399.6, "b": 328.8 }, "text": "Dosage: ___", "reading_order": 13 }, { "page": 5, "type": "TEXT", "location": { "l": 37.68, "t": 322.56, "r": 226.32, "b": 307.68 }, "text": "Expiration Date: ___ / ___ / ___", "reading_order": 14 }, { "page": 5, "type": "TEXT", "location": { "l": 37.92, "t": 301.2, "r": 154.08, "b": 287.28 }, "text": "Refrigerate: ☐ Yes ☐ No", "reading_order": 15 }, { "page": 5, "type": "TEXT", "location": { "l": 37.44, "t": 280.32, "r": 343.92, "b": 265.68 }, "text": "Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM", "reading_order": 16 }, { "page": 5, "type": "TEXT", "location": { "l": 37.2, "t": 258.72, "r": 562.56, "b": 244.56 }, "text": "Special Instructions: ___", "reading_order": 17 }, { "page": 5, "type": "TEXT", "location": { "l": 37.68, "t": 238.32, "r": 565.92, "b": 223.68 }, "text": "Possible Reactions: ___", "reading_order": 18 }, { "page": 5, "type": "TITLE", "location": { "l": 36.96, "t": 203.04, "r": 168.72, "b": 189.6 }, "text": "Medication #3 (if needed)", "reading_order": 19, "level": 3 }, { "page": 5, "type": "TEXT", "location": { "l": 37.44, "t": 182.64, "r": 397.68, "b": 168.72 }, "text": "Medication Name: ___", "reading_order": 20 }, { "page": 5, "type": "TEXT", "location": { "l": 37.44, "t": 161.76, "r": 399.6, "b": 147.84 }, "text": "Dosage: ___", "reading_order": 21 }, { "page": 5, "type": "TEXT", "location": { "l": 37.44, "t": 141.36, "r": 226.56, "b": 126.48 }, "text": "Expiration Date: ___ / ___ / ___", "reading_order": 22 }, { "page": 5, "type": "TEXT", "location": { "l": 37.68, "t": 120.24, "r": 153.6, "b": 106.56 }, "text": "Refrigerate: ☐ Yes ☐ No", "reading_order": 23 }, { "page": 5, "type": "TEXT", "location": { "l": 37.44, "t": 99.12, "r": 344.16, "b": 84.96 }, "text": "Times: ___ AM/PM ___ AM/PM ___ AM/PM ___ AM/PM", "reading_order": 24 }, { "page": 5, "type": "TEXT", "location": { "l": 37.44, "t": 78.24, "r": 562.32, "b": 63.84 }, "text": "Special Instructions: ___", "reading_order": 25 }, { "page": 5, "type": "TEXT", "location": { "l": 37.92, "t": 56.88, "r": 567.36, "b": 42.96 }, "text": "Possible Reactions: ___", "reading_order": 26 } ] }, { "page": 6, "items": [ { "page": 6, "type": "TITLE", "location": { "l": 185.28, "t": 705.6, "r": 448.08, "b": 667.92 }, "text": "Medical Information and Authorization\nPARENT/GUARDIAN AUTHORIZATION AND RELEASE", "reading_order": 0, "level": 1 }, { "page": 6, "type": "TEXT", "location": { "l": 42.24, "t": 628.56, "r": 312.96, "b": 615.84 }, "text": "PARTICIPANTNAME:___", "reading_order": 1 }, { "page": 6, "type": "TITLE", "location": { "l": 40.8, "t": 596.4, "r": 266.4, "b": 582 }, "text": "SECTION 6. MEDICAL AUTHORIZATION", "reading_order": 2, "level": 2 }, { "page": 6, "type": "TEXT", "location": { "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.", "reading_order": 3 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 46.08, "t": 534.48, "r": 137.28, "b": 522.96 }, "text": "I understand that:", "list_id": "L4", "level": 0, "items": [ { "page": 6, "type": "LIST_ITEM", "location": { "l": 54, "t": 518.4, "r": 318.96, "b": 505.68 }, "text": "I am responsible for any medical expenses incurred", "marker": "-", "list_id": "L4", "level": 1, "reading_order": 0 }, { "page": 6, "type": "LIST_ITEM", "location": { "l": 54.72, "t": 501.36, "r": 254.4, "b": 488.88 }, "text": "I will be notified in case of emergency", "marker": "-", "list_id": "L4", "level": 1, "reading_order": 1 } ], "reading_order": 4 }, { "page": 6, "type": "TEXT", "location": { "l": 46.08, "t": 464.16, "r": 405.12, "b": 450.96 }, "text": "Parent/Guardian Name (print): ___", "reading_order": 5 }, { "page": 6, "type": "TEXT", "location": { "l": 46.08, "t": 438.72, "r": 394.8, "b": 425.52 }, "text": "Signature: ___", "reading_order": 6 }, { "page": 6, "type": "TEXT", "location": { "l": 46.56, "t": 413.52, "r": 240.48, "b": 400.08 }, "text": "Date: ___", "reading_order": 7 }, { "page": 6, "type": "TEXT", "location": { "l": 42.72, "t": 393.12, "r": 575.52, "b": 312.48 }, "text": "___", "reading_order": 8 }, { "page": 6, "type": "TITLE", "location": { "l": 35.76, "t": 299.52, "r": 323.52, "b": 282.24 }, "text": "FOR PROGRAM/CAMP STAFF USE ONLY", "reading_order": 9, "level": 2 }, { "page": 6, "type": "TEXT", "location": { "l": 42, "t": 270.48, "r": 399.36, "b": 256.56 }, "text": "Medications Received By: ___", "reading_order": 10 }, { "page": 6, "type": "TEXT", "location": { "l": 42.72, "t": 247.68, "r": 235.92, "b": 234 }, "text": "Date: ___", "reading_order": 11 }, { "page": 6, "type": "TEXT", "location": { "l": 41.76, "t": 224.16, "r": 583.44, "b": 139.44 }, "text": "Notes: ___", "reading_order": 12 }, { "page": 6, "type": "TEXT", "location": { "l": 158.16, "t": 33.36, "r": 422.16, "b": 22.08 }, "text": "Kentucky State University is an equal opportunity provider.", "reading_order": 13 } ] } ]