4-H Medical Information And Informed Consent For Treatment printable pdf download

4-H MEDICAL INFORMATION AND INFORMED CONSENT FOR TREATMENT

FOR NC 4-H SPONSORED EVENTS

4-H’ers Name_____________________________________

PLEASE READ AND COMPLETE THE FOLLOWING FORM. THIS FORM MUST BE PRESENTED AT THE

OFFICIAL REGISTRATION FOR THE 4-H SPONSORED EVENT BEING ATTENDED.

Medical Information

Known allergies to foods, drugs, insect stings or bites, etc: _________________________________________________

Special medical concerns or conditions that event supervisors should know about, including contagious illnesses, epilepsy, asthma,

diabetes, previous injuries to bones/joints, etc.: _________________________________________________________________

List special dietary needs: ________________________________________________________________________

Medications currently being taken (name of medication, dose, and

frequency):__________________________________________________

Family Physician: Name ___________________________________ Phone # (____) ____________

Address________________________________________________________________________

II.

Insurance Information

The 4-H program purchases insurance for youth participants for many sponsored events. In some cases, this coverage will not

pay for some medical expenses and it may be necessary to bill the family or your insurance company.

Health Insurance Company ______________________________________________________________ Health Insurance

Policy # _______________________________________________________________ Company Address

____________________________________________________________________________ Phone Company Telephone

Number (____)___________________________________________

III.

If you are a person with a disability and desire any assistive devices, services or other accommodations to participate in this activity,

please contact __________ [name, office] at __________ [phone number/TTY] during business hours of 8 a.m. and 5 p.m. to discuss

accommodations at least __________ [hours/days] prior to the activity.

Signatures Acknowledging Parts I, II, and III

Parent's/Guardian's signature _____________________________ Date:______________

Participant's Signature: ____________________________________________ Date: __________________

Parent/Guardian telephone #: Home _______________________ Work ________________________

1of 2

Must be completed each year by 4-H’er and Parent/Guardian. If health history changes within that year, it is the 4-H’er & Parent/Guardian’s responsibility for updating

information.

Approved as of 3/02/06

4-H Medical Information And Informed Consent For Treatment

Related Articles

Related forms

Related Categories