Confidential
Confidential
HEALTH HISTORY
[This Box to Be Completed by ACES Staff]
Does the youth have – or has ever had -- any of the
County: _________________________________
following? Check Yes or No to each item.
Date of Receipt by County: ______/______/______
Please explain any Yes answers (noting the number of
the item) in the space below or on additional paper.
Reporting a health condition will not prevent you from
Alabama 4-H
participating and will be kept confidential.
Youth Consent Form
Yes No
1. Asthma ...................................................
All items on this form must be completely filled out by the
2. Bronchitis ................................................
participant and his or her parent or guardian. If an item is not
3. Convulsions ............................................
applicable or there is none, indicate that by using N/A or
4. Diabetes ..................................................
None (for example: no Family Doctor). If this form is not
5. Ear Infection ............................................
completed in its entirety, the youth will not be able to
participate in 4-H activities.
6. Fainting ...................................................
7. Heart Condition .......................................
8. Headaches ..............................................
Youth’s Name _________________________________
9. Hypoglycemia .........................................
Last
First
10. Serious Insect Stings ..............................
Birth Date____/____/____ Age____
Female
Male
11. Wear Glasses .........................................
Month / Day / Year
12. Wear Contact Lenses ..............................
Home Address _______________________________
13. Other Conditions .....................................
_______________________________
14. Penicillin Allergy ......................................
City
State
Zip
15. Aspirin Allergy .........................................
Home Phone (
) ___________________________
16. Tetanus Allergy .......................................
Parent/Guardian Work Phone (
) ________________
17. Other Drug Allergies ...............................
18. Food Allergies .........................................
Family E-mail _________________________________
19. Serious Ivy, Oak or Sumac Poisoning ….
Cell Phone (
) ____________________________
20. Other Allergies ........................................
Date of Last Tetanus Shot ____/____/____
Primary Emergency Contact ______________________
Phone(s) (
) ________________________________
Please explain Yes answers and provide information on
present medications, recent medical issues (including injuries
Alternate Emergency Contact _____________________
and surgeries), allergic reactions, special dietary regulations,
Phone(s) (
) _______________________________
any specific activities to be restricted and other comments.
_____________________________________________
_____________________________________________
Youth’s Doctor ________________________________
_____________________________________________
Phone (
) ________________________________
_____________________________________________
Health Insurance Co. ___________________________
_____________________________________________
Policy # ______________________________________
_____________________________________________
Name of Insured _______________________________
_____________________________________________
Relationship to Participant _______________________
_____________________________________________
ATTACH A PHOTOCOPY OF YOUR INSURANCE CARD
_____________________________________________
Publicity Release
_____________________________________________
I authorize Alabama 4-H or its assignees to record or
These over-the-counter medications or generic
photograph my image and/or voice and that of my child (if
equivalents may be administered to my child without
under 19) for use in research, educational and promotional
contacting me: Antihistamine (Benedryl) Antacid
programs and hereby convey all rights in perpetuity in such
Ibuprofen (Advil)
Acetaminophen (Tylenol)
recording, photo, video or other media rights, including but
Pepto-Bismol Decongestant Baby Aspirin
not limited to Alabama 4-H or its assignee. I also recognize
that these audio, video and image recordings are the
Hydrocortisone
Polysporin (antibiotic cream)
property of Alabama 4-H.
_____________________________________________
No, I do not authorize use of my – or my child’s –
Please contact me for permission prior to
individual image or voice.
administering any over-the-counter medications.
This form is valid for one year from signing. Please update all medical or other information as needed.
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