Waiver, Indemnification, And Medical Treatment Authorization Form Page 3

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HEALTH STATEMENT
Check one:
Youth
Adult
County
th
th
th
Event:
District 8 4-H County Camp
Event Dates:
July 8
, 9
, 10
, 2016
The proposed activity provided by the 4-H County Camp, requires participation in physical exercises, which are, by their nature, physically
demanding. Many of the activities will challenge you, and cause surges in blood pressure and pulse rates. It is imperative that you are free of any
heart related or other disease. Therefore, all participants must be free of medical or physical conditions which might create undue risks to
themselves or any others who depend on them. If there is any doubt about your ability to safely participate in this experience, you should have a
physical examination.
Section I. Participant Information
Name
Date of Birth
Age
Gender
Address
Name of Physician
City, State, Zip
Physician’s Phone
Home Phone
Date of Last Physical Exam
Section II. In the event of an emergency, please contact:
Name
Home Phone
Address
Work Phone
City, State, Zip
Mobile Phone
Name
Home Phone
Address
Work Phone
City, State, Zip
Mobile Phone
Section III. Health History
Have you had or do you currently have any heart problems (dates):
Yes
No
Do you frequently suffer from pains in your chest:
Yes
No
(NOTE: If you have any heart related problems you will need to have a physician’s release.)
Do you often feel faint or have spells of severe dizziness:
Yes
No
Has a doctor ever told you that you might have high blood pressure:
Yes
No
Are you a smoker:
Yes
No
Do you have arthritis, joint, or back problems that can be aggravated by exercise:
Yes
No
Have you had any operations or serious injuries (dates):
Yes
No
Do you have any chronic recurring illness or communicable diseases:
Yes
No
Are there any activities to be limited/discouraged by a physician’s advice:
Yes
No
Are you allergic to any medications, food or food ingredients, insects, or pollens:
Yes
No
Do you have Epilepsy:
Yes
No
Do you have Diabetes:
Yes
No
Do you have any prescribed meal plan or dietary restrictions (please describe)
Yes
No
Any other health related information for Camp personnel to be aware of:
Yes
No
Section IV. Medications (ALL medications must be in ORIGINAL container with ORIGINAL LABEL.)
Are there prescribed medications currently being taken (please describe):
Yes
No
Please check “over the counter” medications which camp personnel may administer as necessary:
Immodium
Pepto Bismol
Ibuprofen (Motrin)
Acetaminophen (Tylenol)
Neosporin
Benadryl
Calamine/Caladryl
Any as needed
Section V. Insurance Information
Do you carry family medical/hospital insurance?
Yes
No
Carrier:
Policy Number:
Signature of Participant
Date
(Or guardian if participant is under the age of 18)
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