National 4-H
Shooting Sports Ambassadors Health Form
Participant’s
Name ________________________________________________________________
Sex________
Last
First Middle Initial Nickname
Age as
of Jan. 1of current year _____________ Birth date ____________________
Complete
Home Address____________________________ Telephone: day ( _____ )
______________
___________________________________________________
Telephone: evening ( _____ ) ______________
Name of
Custodial Parent/Guardian_____________________________________________________________
Home
Telephone ( _____ ) __________________________ Work Telephone ( _____ )
___________________
Name of
Non-Custodial Parent/Guardian
________________________________________________________
Home
Telephone ( _____ ) __________________________ Work Telephone ( _____ )
___________________
If
Parent/Guardian is not available in an emergency, contact:
_____________________________________
Telephone
( _____ ) __________________________ Relationship to
Individual_________________________
Family
Primary Care Physician __________________________________ Telephone ( _____ )
____________
Family
Dentist _________________________________________________ Telephone ( _____ )
____________
Family
Health Insurance
Carrier_________________________________________________________________
Policy
Number ________________________________________________ Name of Insured
______________
No
Insurance Coverage
Insurer
requires authorization from primary care physician prior to treatment.
Health History
Check
all that apply; give approximate date of onset
____Frequent
Ear Infections ____Heart Defect/Disorder ____High Blood Pressure
____Seizure
Disorder/Convulsions ____Diabetes ____Bleeding Clotting Disorders
____Mononucleosis
____Sleep Walking ____ADD/AD HD
____Asthma
____Chicken Pox ____Measles
____German
Measles (Rubella) ____Mumps ____Hepatitis
____Menstrual
Cycle Started ____Urinary Tract Infection ____Head Injury
____Bed
Wetting ____Recent Surgery: Please explain___________________________
Please
list any additional important health information or dietary re s t r i c t i o
n s .
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Allergies Check all that apply.
_____Hay
Fever _____Insect Stings* _____Iodine
_____Poison
Ivy, Oak, etc. _____Penicillin _____Other allergies: Please List Below
_____Insect
Bites _____Sulfa _____Foods allergies: Please List Below
_______________________________________________________________________________________________
_____This
individual requires immediate medical attention for treatment of allergies —
please specify.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Immunization History
Please
record month and year of basic immunizations and most recent booster doses.
Vaccines Year of Basic Immunization Year of Last Booster
Diphtheria
Pertussis
Tetanus
Chickenpox
Oral
Polio
Injectable
Polio
Measles
Mumps
Rubella
TB Test
Haemophiles
influenza B / /most recent:
Hepatitis
B
Other
Medications
Please
list ALL medications the individual routinely takes. Bring at least enough
medication to last for the prog
r a m ’s
duration. Keep medication in the original container, which identifies the name
of the medication, its
dosage, and frequency of administration; the prescription number; and the physician’s name and phone number.
Prescription
Medication Dosage Specific Times Taken Reason For Taking
Non-Prescription
Medication Dosage Specific Times Taken Reason For Taking
Individual
requires no regular medication.
I give
permission to the selected National 4-H Shooting Sports Staff or volunteer to administer the
medications listed above, along with
any of
the following additional medications that I have checkmarked, if the staff or
volunteer deems it necessary.
_____Acetaminophen
______Aspirin _______Ibuprofen _______Pepto Bismol
_____Calamine
lotion ______Immodium AD _______Cough drops _______Sunscreen
Dosages
will be administered according to directions on the container unless a
physician directs otherwise.
Additional
information, for medical staff only, may be attached in sealed envelope.
___________________________________________
__________________________________ _______________
Signature of Participant or Parent/Guardian if Print Name of
Parent/Guardian Date
participant is under 18 years old
Participation
This
participant is allowed to participate fully in this
_____________________________________________,
which
may include swimming, canoeing, hiking, sports, and other strenuous
events/activities.
Yes No
Specify restriction__________________________________________________________
Additional
information for health care staff:
__________________________________________________________
____________________________________________________________________________________________________
______________________________________________
_________________________________ _______________
Signature of Participant or Parent/Guardian if Print Name of
Parent/Guardian Date
participant is under 18 years old
AUTHORIZATION FOR PARTICIP ATION AND RELEASE: I hereby give permission for
medical personnel
selected
by National 4-H Shooting Sports
program to provide routine health care; to order x-rays, and
routine
tests; to administer medications, injections, anesthesia, surgery, and other
treatment; to release
records
necessary for insurance purposes; and to provide or arrange necessary related
transportation for
me/my
child. In the event I cannot be reached in an emergency, I hereby give
permission for medical personnel
selected
by the National 4-H Shooting Sports Porgram to secure and administer treatment
including hospitalization for the participant
named
above. I further understand that I will be responsible for medical/hospital
bills. By signing this
form, I
give permission for the participant named above to participate in all program
activities except as
specified
herein. This completed form may be copied for trips out of camp and/or away
from the program
site. By
signing this form, I release and forever discharge, agree not to sue, and to
indemnify and hold
harmless the National 4-H Shooting Sports program and/or their officers, agents, employees, faculty, staff, and volunteers from and against any and all liabilities, costs, expenses, causes of action, claims, and/or demands in any way relating to the foregoing program activities
and/or
the health, illness, injury, and/or treatment of the participant named above.
I AM 18 YEARS OLD OR OLDER AND I HAVE READ AND FULLY UNDERSTAND
THIS AUTHORIZA -
TION FOR PARTICIP ATION AND TREATMENT AND RELEASE.
_________________________________________
_______________________________________ _______________
Signature of Participant or Parent/Guardian Print Name of
Participant or Parent/Guardian Date
if participant is under 18 years old if participant is under 18
years old
(Or)
_________________________________________
_______________________________________ _______________
Signature of Parent/Guardian of Print Name of Parent/Guardian of
Date
18 year old (optional) 18 year old (optional)
THIS SECTION FOR OVERNIGHT RESIDENTIAL PROGRAM PARTICIPANTS ONLY.
HEALTH EXAM To
be completed by doctor
Participation
This
individual is allowed to participate fully in this program, which may include
swimming, canoeing,
hiking,
sports, and other strenuous events:
Yes No
Specify restriction ______________________________________________________
Additional
information for health care staff: _______________________________________________________
_________________________________________________________________________________________________
I have
examined this individual within the past 2 years. Date Examined / /
Height
_______________ Weight _______________ Blood Pressure _______________
Currently
under care of physician for
_____________________________________________________________
________________________________________
_____________________________________ ______________
Signature of Physician Print
Name of Physician Date
____________________________________________ _________________________________________ ________________
N u r s e / P h y s i c i a n ’ s Assistant completing form Print
Name of Nurse/Physician’s Assistant D a t e
(Program
name)
Personal Identification Form
In an effort to
provide a safe and enjoyable educational experience, we ask that you complete
this
information. This
information will be used in case of an emergency to help mobilize assistance
and to
distribute to those
providing assistance.
Participant’s
Name_____________________________________________
Telephone: (
____________ ) ____________________________________
Address________________________________________________________
_______________________________________________________________
_______________________________________________________________
Parent/Guardian
Name _________________________________________
Emergency
Contact: ___________________________________________
Telephone: (
____________ ) ____________________________________
Individual’s
Physical
Description______________________________________________________________________
____________________________________________________________________________________________________
Age _________ Sex
_________ Race _________ Height _________ Weight _________
Hair Color
_______________ Eye Color _______________ Glasses Yes No Contacts Yes No
Facial
Features/Shape
________________________________________________________________________________
Teeth (
Distinguishing
Marks/Scars
___________________________________________________________________________
Physical
Condition __________________________________________________________________________________
Mental Condition
___________________________________________________________________________________
Emotional
Condition
________________________________________________________________________________
Hobbies & Interests
of Individual
_____________________________________________________________________
Personal/Family
situation that could cause concerns:
___________________________________________________
____________________________________________________________________________________________________
Other
habits/personality information that could be helpful
____________________________________________
____________________________________________________________________________________________________
Recent Photograph
(Within Past
Year)