Virginia Cooperative Extension
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24-H Health History
Report Form
Revised 2009
publication 388-906
instRuctions: Please provide detailed health information for determining appropriate supervision, support, and accommodations for the
4-H activity or event listed. a parent or guardian must sign. If the participant is a person with a disability and desires any assistive devices,
services or other accommodations to participate in this activity, please contact your local Extension office during business hours at least 7 days
prior to the event to discuss accommodations. please pRint all inFoRMation. (NOTE: Both sides of this form must be completed.)
NAME OF 4-H EVENT IN WHICH YOU WISH TO PARTICIPATE: _______________________________________________________
DATE(S) OF EVENT: ____________________________ LOCATION: ___________________________________________________
paRticipant identiFication
NAME: ______________________________________________________________________________
FEMALE:
MALE:
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Last
First
Middle
(Underline name by which you like to be called)
MAILING ADDRESS: __________________________________________
PARTICIPANT CELL PHONE: (______) ____________
CITY: _______________________ STATE: _____ ZIP: _____________
HOME PHONE: ( ______ ) _____________________
AGE: __________
BIRTHDATE: ___________________
HOME EMAIL: _______________________________
RACE: (Optional)
WHITE
HISPANIC
BLACK
AMERICAN INDIAN
ASIAN
MULTICULTURAL
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paRent / GuaRdian identiFication (Place a check beside who to reach in the event of an emergency.)
o FATHER’S NAME (OR GUARDIAN): _________________________________ FATHER’S EMAIL: ___________________________
FATHER’S PHONE DAYTIME: ______________________ EVENING: ______________________ CELL: _______________________
o MOTHER’S NAME (OR GUARDIAN): _______________________________ MOTHER’S EMAIL: ___________________________
MOTHER’S PHONE DAYTIME: _____________________ EVENING: ______________________ CELL: _______________________
WHO HAS PRIMARY CUSTODY OF THE PARTICIPANT? _____________________________________________________________
ADDRESS, IF DIFFERENT THAN CHILD: __________________________________________________________________________
pHYsician / insuRance inFoRMation
4-H paRticipant Media Release
FAMILY PHYSICIAN NAME: ____________________________________________
The Virginia Polytechnic Institute and
State University/College of Agriculture
PHONE: ( ________ ) _________________________
and Life Sciences (CALS) periodically
DENTIST / ORTHODONTIST NAME: _____________________________________
uses electronic and traditional media
PHONE: ( ________ ) _________________________
(e.g., photographs, video, audio
footage, testimonials) for publicity and
do You caRRY FaMilY Medical / Hospital insuRance?:
Yes
no
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educational purposes. By my signature
(Check √ one)
CARRIER: ______________________________________________
on this form, I acknowledge receipt
POLICY ID #: _____________________________________________
of this document and give permission
to the College of Agriculture and Life
eMeRGencY contact inFoRMation (Parts 1 and 2 should be completed)
Sciences and its designee to use such
1. WHERE CAN YOU BE REACHED IN THE EVENT OF AN EMERGENCY?
reproductions for educational and
LOCATION:________________________________________________________
publicity purposes in perpetuity without
further consideration from me.
PHONE: ( ______ ) __________________________
I understand that I will need to notify
CELL PHONE: ( ______ ) _____________________
Virginia Tech/College of Agriculture
2. IF YOU cannot BE REACHED, WHO SHOULD BE NOTIFIED?
and Life Sciences if any changes to
NAME: ___________________________________________________________
my situation occur that will impact this
HOME PHONE: ( ______ ) ____________________
media release permission.
WORK PHONE: ( ______ ) ____________________
CELL PHONE: ( ______ ) _____________________
Yes
no
(continued on back)
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* 18 U.S.C. 707
Produced by Communications and Marketing, College of Agriculture and Life Sciences,
Virginia Polytechnic Institute and State University
Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion,
age, disability, political beliefs, sexual orientation, or marital or family status. An equal opportunity/affirmative action employer.
Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University,
and the U.S. Department of Agriculture cooperating. Mark A. McCann, Director, Virginia Cooperative Extension, Virginia Tech,
Blacksburg; Alma C. Hobbs, Administrator, 1890 Extension Program, Virginia State, Petersburg.
VT/0108/W/388906
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Parent category: Medical