Florida 4-H Participation Form For Youth And Adults printable pdf download

Florida 4-H Participation Form for Youth and Adults

Directions: This form, along with a Florida 4-H Youth Enrollment Form, must be completed by a parent or legal guardian in order for a youth to par-

ticipate in the Florida 4-H Program. All items must be completed. Even if the response is not applicable – indicate by using N/A. Failure to complete

this form in its entirety will result in the person being ineligible to participate in 4-H activities. Adult participants must also complete this form to volun-

teer with and/or participate in Florida 4-H.

Name: _________________________________________ Birthdate: ____/____/____ Youth’s Age (As of Sept.1, 2016): _____ Male or Female: ____

Last

First

Home Address: _____________________________________________ 4-H County/District ______________________________________________

City, ST, Zip: ______________________________________________ Home Phone ( _______ ) __________________________________________

Name of Parent/Guardian or Emergency Contact: ______________________________Relationship to Participant: ____________________________

Emergency Contact Primary Phone ( _______ ) _____________________________

Name of Family Doctor: _________________________________ Doctor’s Office Phone: ( _____ ) ________________________________________

Health Insurance Company: _______________________________ Policy #: __________________________________________________________

Name of Insured: ______________________________________________ Relationship to Participant: ______________________________________

HEALTH FORM

Does the participant have, or at any time had, any of the following? Check “Yes” or “No” to each item. Please explain any “Yes” answers (noting

the # of the item) in the space below or on an additional sheet of paper if necessary. Reporting conditions will not prevent a person from attending

and will be kept confidential.

The following over-the-counter medications

Conditions

Yes

Conditions

Yes

may be administered to my child, without

1) Asthma

contacting me. Check all that apply.

12) Wear Contact Lenses

□ Antihistamine

2) Bronchitis

13) Penicillin Allergy

□ Antacid

3) Convulsions

14) Aspirin Allergy

□ Ibuprofen (Advil)

4) Diabetes

15) Tetanus Allergy

□ Acetaminophen (Tylenol)

□ Hydrocortisone

5) Ear Infection

16) Other Drug Allergies

□ Decongestant

6) Fainting

17) Food Allergies

□ Dramamine

7) Heart Condition

18) Serious Ivy, Oak, or Sumac

□ Polysporin (topical antibiotics)

□ Aloe Vera Gel for Sunburn

8) Headaches

19) Sunscreen Allergies

□ Please contact me for permission to adminis-

9) Hypoglycemia

20) Other Allergies

ter ANY over-the counter medications.

10) Serious Insect Stings

21) Other Health Conditions

Date of Last Tetanus Shot ____/____/_____

11) Wear Glasses

Please explain “Yes” answers and provide information on recent medical issues (including injuries and surgeries), allergic reactions, special dietary regulations,

present medications, any specific activities to be restricted and other comments.

_____________________________________________________________________________________________________________________________________

Does the participant use an inhaler and/or an EpiPen? □ Yes

□ No

If yes, mark which is used:

□ Inhaler

□ EpiPen

Disabilities: If the participant requires accommodations for a disability to participate in 4-H programs, please provide information about the disability.

______________________________________________________________________________________________________________________

Special Needs: If the participant requires accommodations for special needs to participate in 4-H programs, please provide information about the special needs.

______________________________________________________________________________________________________________________

Medical Consents

First Aid Consent: I give UF/IFAS Extension Florida 4-H my consent and permission to render general first aid treatment to my child or myself for any injuries or

illnesses occurring during any Florida 4-H activity. I understand that if a medical emergency arises, Florida 4-H will contact emergency medical personnel [911] for

assistance.

Medication Consent: I authorize Florida 4-H to administer medication (over the counter and/or prescribed) to my child as specified in the physician’s written instruc-

tions or instructions on packaging. I understand that if my child needs medication to be administered while attending a Florida 4-H activity, I MUST complete

the Florida 4-H Medication Form in addition to signing this consent.

_______ (Initials) □ Yes

□ No

I understand and agree to the Medical Consents. I am a Parent/Guardian or Adult Participant. *

* Consent is required to participate in Florida 4-H.

Revised July 1, 2016 for the 2016-2017 4-H Year

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