Georgia 4-H Medical Information Release Form

Georgia 4-H Medical Information & Release
Event or Activity
Date of Event/Activity
4-H’ers Information
Name
Address
Date of Birth
Grade
Gender
Parent/Guardian Information
Name
Home Phone:
Work Phone:
Cell Phone:
Please list the names of two adults other than parent/guardian who may be contacted in case of
emergency.
Name
Home Phone
Work Phone
Name
Home Phone
Work Phone
Medical Information
Name of Physician
Phone
Date of Last Physical Examination
Drug Allergies
Other Allergies
Describe any physical limitations
Describe any recent illness or injury
Is there a history of heart condition
diabetes
asthma
epilepsy
rheumatic fever
PARENT/GUARDIAN AGREEMENT:
I understand that should a health problem arise, I will be notified but that if I can not be reached by telephone, such medical treatment,
including surgery, as deemed necessary by competent medical personnel could be rendered; that such necessary information may be
released for insurance purposes and that I understand the limitation of the coverage as indicated below. Furthermore, I am aware that
participation in this event includes risk including, but not limited to, transportation to/from event, sports and recreational games, ropes
courses, water activities, hiking, as well as risks that are not foreseeable. For the sole consideration of the Cooperative Extension Service’s
arranging for participation in 4-H programming, I hereby release and forever discharge The University of Georgia, the Board of Regents of
the University System of Georgia, their members individually, and their officers, agents and employees from any and all claims, demands,
rights and causes of action of whatever kind that I may have, either on my own behalf or in my capacity as a legal representative of my child,
arising from or in any way connected with my child’s participation in 4-H. I further covenant and agree that for the consideration stated
above I will not sue the Institution, the Board of Regents of the University System of Georgia, it’s members individually, its officers, agents or
employees for any claim for damages arising or growing out my child’s participating in the program. I understand that the acceptance of this
Release, Waiver of Liability, and Convent not to Sue the Board of Regents of the University System of Georgia shall not constitute a waiver, in
whole or part, of sovereign immunity by said Board, its members, officers, agents, and employees. I certify that my child is participating in
4-H with my knowledge and consent. I have read and understand all of the above policies
____________________________________
_____________
Parent/Guardian Signature
Date
INSURANCE COVERAGE INFORMATION (to be completed by County Extension personnel)
Insurance for the event/activity has been purchased as indicated. For complete details of coverage,
please contact the county Extension Office.
!" Insurance for Summer Camp at Georgia 4-H Centers
!" American Income Life Insurance (Plan 3)
!" American Income Life Insurance (Dollar a Year Plan)
!" Other Insurance Plan _________________________________
PLEASE COMPLETE BOTH SIDES
Over the Counter & Prescription Medication Summary
4-H’ers Name
County
Please list any/all medication currently being taken by the 4-H club member including prescription and
over the counter medications. Additionally, parent/guardian should list any over the counter medication
that may be given to the 4-H’er in case of illness. 4-H personnel may not administer over the counter or
prescription medication without parental/guardian approval unless prescribed by medical personnel.
4-H’ers are expected to provide all medication(s) listed and administer the medication. If health facilities
and/or personnel are available at the facility, a request may be made prior to the event to have
medication administered by trained personnel. Additional copies of this page may be made as necessary.
Name of Medication:
What illness/condition is medication being taken for:
Describe dosage and special instructions:
Is medication self administered?
Dates for administration:
Name of Medication:
What illness/condition is medication being taken for:
Describe dosage and special instructions:
Is medication self administered?
Dates for administration:
Name of Medication:
What illness/condition is medication being taken for:
Describe dosage and special instructions:
Is medication self administered?
Dates for administration:
I am the parent/guardian of ______________________and give permission for the medications listed to be
administered to my child as directed.
__________________________________________
Parent’s signature
_______________
Date
PLEASE COMPLETE BOTH SIDES