4-H Medical Information And Informed Consent For Treatment (Page 2 of 2) in pdf

IV.

Informed Consent

In the event that a participant needs minor medical care from 4-H or more significant medical care from

a qualified health care provider, including in rare cases possible hospitalization and/or surgery, the

parent/guardian is asked to sign the informed consent form below. In case of serious medical condition,

4-H will make every effort to notify the parents, but the first priority may be providing care to the

participant.

Authorization to Consent to Health Care for Minor

I, _______________________________________, of ________________________ County, am the custodial

parent having legal custody of __________________________, a minor child, age ________, born

_____________________________. I authorize any adult(s) acting as agents (including official volunteers) or

employees of the ________________________ 4-H program and in whose care the minor child has been

entrusted , to do any acts which may be necessary or proper to provide for the health care of the minor child,

including , but not limited to, the power (i) to provide for such health care at any hospital or other institution, or

the employing of any physician, dentist, nurse, or other person for such health care, and (ii) to consent to and

authorize any health care, including administration of anesthesia, X-ray examination, performance of

operations, and other procedures by physicians, dentists, and other medical personnel except the withholding or

withdrawal of life sustaining procedures.

This consent shall be effective for one year from the date of the execution.

Custodial Parent Signature_______________________________________Date_______

STATE OF NORTH CAROLINA

COUNTY OF _________________________

On this _________ day of ________________, 20___, personally appeared before me the said named,

_____________________________, to me known and known to me to be the person described in and who

executed the foregoing instrument and he (or she) acknowledged that he (or she) executed the same and being

duly sworn by me, made oath that the statements in the foregoing instrument are true.

My commission expires ________________________________________, 20_____.

Notary Public

(OFFICIAL SEAL)

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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 Page 2

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