Adult Medical Release Form - Ucce Orange County (Page 2 of 2) in pdf

University of California Division of Agriculture and Natural Resources

4-H Youth Development Program

Health History Information

_________________________________________________

________________________

______/_______/______

First Name

Last Name

County

Date of Birth

Subject to:

Yes

Now Have or Have Had

Yes

Colds

Heart Trouble

Sore Throat

Asthma

Fainting Spells

Lung Trouble

Bronchitis

Sinus Trouble

Convulsions

Hernia (rupture)

Cramps

Appendicitis

Allergies

Has appendix been removed?

Wear corrective lenses?

Do you walk in your sleep?

Is hearing good?

Date of last Tetanus Vaccination: ____________________________

Please identify allergies including allergies to food, medications, and drug reactions:

Please list any disability accommodations you will need in order to participate in this program or activity.

Please list all current medications:

Name of Medication

Dosage

Times Taken

Please include any additional remarks and special instructions to better assist emergency service personnel.

Please explain “yes” answers on this page.

The University of California prohibits discrimination or harassment of any person on the basis of race, color, national origin, religion, sex, gender identity, pregnancy (including

childbirth, and medical conditions related to pregnancy or childbirth), physical or mental disability, medical condition (cancer-related or genetic characteristics), ancestry, marital

status, age, sexual orientation, citizenship, or service in the uniformed services (as defined by the Uniformed Services Employment and Reemployment Rights Act of 1994: service

in the uniformed services includes membership, application for membership, performance of service, application for service, or obligation for service in the uniformed services) in

any of its programs or activities. University policy also prohibits reprisal or retaliation against any person in any of its programs or activities for making a complaint of

discrimination or sexual harassment or for using or participating in the investigation or resolution process of any such complaint. University policy is intended to be consistent

with the provisions of applicable State and Federal laws. Inquiries regarding the University’s nondiscrimination policies may be directed to the Affirmative Action/Equal

Opportunity Director, University of California, Agriculture and Natural Resources, 1111 Franklin Street, 6th Floor, Oakland, CA 94607, (510) 987-0096.

4-H 1110 (Rev 9/2008)

Adult Medical Release Form - Ucce Orange County Page 2

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