Nh 4h Health And Medication Form (Page 2 of 2) in pdf

Medication

List any medications currently being taken. Include prescription and non‐prescription. PLEASE INCLUDE DOSAGES

For minor participants only:

1. Will medications need to be administered during the program?

YES

NO If yes, please list and see note below*

2. I give permission for the program participant to self‐administer the medication identified and that s/he has the knowledge

and skills to safely use the medication.

YES

3. A staff member/volunteer leader may administer (check all that apply):

Benadryl (diphenhydramine)

Tylenol (acetaminophen)

Motrin (ibuprofen)

Antacids

*If medications must be administered to a minor during a program, please contact the program staff or volunteer leader to

discuss specifics and note that:

1. All medications MUST be carried in the container in which they were issued, prescriptions must include medical orders and

physician's name.

2. Any medications brought to 4‐H events should be the exact amount required and should be kept with a responsible adult

until administration, with the possible exception of Epi‐Pens and Asthma Inhalers

The program participant as named on this Health and Medication Form is physically able to participate in this program

including handling their project animals, if animals are involved. I understand that if a serious illness or injury develops,

medical and/or hospital care will be given; however, the sponsor is not responsible in case of accident or illness. I further

understand that in case of medical emergency, that the emergency contacts listed on this form will be contacted. If the

program participant named on this form is a minor, I hereby give permission in the case of a medical emergency to the

attending physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the

program participant. I will assume all financial obligations incurred if not covered by insurance. I understand this form

will be in the possession of the appropriate program staff or volunteer leaders.

I certify that I am the parent/guardian of the above named child (or I am 18 years of age and legally eligible to sign for

myself) and that the information set forth on this form is true and correct to the best of my knowledge. I agree that I will

update this form as my/my child’s condition/medications change.

Parent/Guardian Signature:

Date

Valid for All NH 4‐H Club, County and State Events between October 1, 2015 and September 30, 2016

University of N.H. Cooperative Extension is an equal opportunity educator and employer.

University of New Hampshire, U.S. Department of Agriculture and N.H. counties cooperating.

09/15

Nh 4h Health And Medication Form Page 2