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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

<div style="text-align: center;"><img src="imgs/img_in_image_box_193_1557_2266_2020.jpg" alt="Image" width="81%" /></div>


Dietary Considerations or Special Needs

<div style="text-align: center;"><img src="imgs/img_in_image_box_194_2187_2261_2651.jpg" alt="Image" width="81%" /></div>


Current Medications

<div style="text-align: center;"><img src="imgs/img_in_image_box_192_2746_2251_3202.jpg" alt="Image" width="80%" /></div>


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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

Surgery of any kind? ☐ Yes ☐ No

Currently taking medications? ☐ Yes ☐ No

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

Fainted during exercise? ☐ Yes ☐ No

Dizziness during or after exercise? □ Yes □ No

Chest pain during or after exercise? □ Yes □ No

High blood pressure? ☐ Yes ☐ No

Heart murmur? □ Yes □ No

Rapid heartbeat episodes? □ Yes □ No

Family history of heart problems before age 50?

□ Yes □ No

Skin problems? ☐ 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

Breathing issues during activity? ☐ Yes ☐ No

Use of medical equipment? ☐ Yes ☐ No

Vision problems? □ Yes □ No

Bone/joint injuries? ☐ Yes ☐ No

Missing paired organ? □ Yes □ No

## Additional Information

Asthma diagnosis? □ Yes □ No

Tobacco use? □ Yes □ No

Use of inhaler? □ Yes □ No

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

Use insulin? □ Yes □ No

Other medical problems? ☐ Yes ☐ No

Can the participant swim? ☐ Yes ☐ No

Date of last tetanus shot: _____

Diabetes? □ Yes □ No

Injury in the last year? ☐ Yes ☐ No

Explain any “Yes” responses:

___

___

___

___

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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: ___