Voluntary Release Of Liability, Hold Harmless, Indemnification, Assumption Of Risks, And Informed Consent For Water Sports Activities Form/alabama 4-H Youth Consent Form Page 2

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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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