Nh 4h Health And Medication Form
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2NH 4‐H Health and Medication Form
Participant Information
Male
Female
Full Name
Birth Date
Home Address
City/State/Zip
Home Phone
Notify in case of Emergency
(Emergency Contacts will be notified in order listed until one contact is reached):
Name/Relationship
Name/Relationship
Address
Address
City/State/Zip
City/State/Zip
Home Phone Work Phone Cell Phone
Home Phone Work Phone Cell Phone
Allergies
ood Allergies (List food)
Life Threatening?
F
YES
NO
(List medications)
Life Threatening?
Medication Allergies
YES
NO
Allergies (List Insect)
Life Threatening?
Insect
YES
NO
(List)
Life Threatening?
Other Allergies
YES
NO
Personal Medical History
Tetanus Immunization/Date of Last Booster:
Current/chronic health problems, or recent surgery/hospitalization? check yes if any apply
YES
NO
If yes, please explain
(attach another piece of paper if necessary):
Current emotional, behavioral or mental health challenges we should know about?
YES
NO
If yes, please explain and include accommodations or ways of responding that might be helpful
(use another piece of paper if necessary):
Physical Limitations?
YES
NO
If yes, please explain and include accommodations that might be helpful
(use another piece of paper if necessary):
(continued on next page)
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Parent category: Medical