University of California Division of Agriculture and Natural Resources
4-H Youth Development Program
Adult Medical Release Form
This Medical Release Form is authorized for all 4-H Youth Development meetings and activities during the dates specified below:
_________________________________________________ ______________________ to _______________________
County and State
Dates (From / To)
While I am attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE ADULT 4-H LEADER OR 4-H STAFF MEMBER, or in
his/her absence or disability, any adult accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING MEDICAL TREATMENT FOR ME
SHOULD I BE UNABLE TO MAKE A DECISION:
Any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the
general or special supervision of any physician and/or surgeon licensed under the provisions of the Medical Practices Act, California Business and Professions
Code Section 2000 et seq.; or any x-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered by a dentist licensed
under the provisions of the Dental Practices Act, California Business and Professions Code Section 1600 et seq.
This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective until I complete
my activities in this program unless sooner revoked in writing. I understand that I will be responsible for the cost of any service or treatment provided not
covered by the 4-H Accident/Sickness Insurance Program sponsored by UC Cooperative Extension.
Emergency Contact Information
Relationship to Adult Identified Above
Emergency Day Phone (with area code)
Emergency Night Phone (with area code)
Authorization and Consent and Release
I hereby certify that I am in good health and can travel to and participate in all functions of the 4-H Youth Development Program as described
above. I understand is it my responsibility to keep the information on this form updated (including Health History) by contacting the State 4-
I do not desire to sign this authorization and understand that this will prohibit me from receiving any non-life threatening medical attention in
the event of illness or accident.
University policy and the State of California Information Practices Act of 1977 require the following information be provided when collecting personal information from you:
The information entered on this form is collected under authority of the Smith-Lever Act. Submission of the medical data is voluntary. However, a signature is required on one
or the other of the two signature lines above. Failure to provide the medical information and authorization may result in our inability to provide necessary medical treatment.
You have the right to review University records containing personal information about you, with certain exceptions as set forth in policy and statute. Copies of University policies
pertaining to the collection, use, or release of personal data are available for your examination from the local UCCE County Director, 4-H Youth Development Advisor, 4-H
Program Representative or the State 4-H Director of the California 4-H Youth Development Program, University of California, DANR Building, One Hopkins Road, Davis, CA
95616-8575, (530) 754-8518. Only your own records are open to your review.
Any known or foreseeable intergovernmental transfer that may be made of the information is as follows: None.