4-H Participant/Member Health History Form

Ohio 4-H Participant/Member Health History Form

Print form and complete. This form must be completed for each participant. This form is to be completed by parent/guardian of 4-H member. The information will be kept confidential and used only for the welfare of the participant. PLEASE PRINT OR TYPE LEGIBLY!

Date_____________________

County___________________________________ Cabin # (for 4-H Camp only)______________

Please Circle: Male Female Age__________ Date of Birth_______________________

Name: (Last, First, Middle)___________________________________________________________

Address: (Street)___________________________________________________________________

City, State, Zip:____________________________________________________________________

Home Phone:_____________________ Parent/Guardian's Work Phone:_______________________

In case of emergency contact:

Parent Name_______________________________ Phone________________________________

Cell Phone_________________________________ Pager________________________________

Other Person_______________________________ Phone_______________________________

Physician's Name____________________________________ Phone_______________________

Dentist's Name______________________________________ Phone_______________________

Instructions for Medications

All prescription drugs MUST be carried in the container in which they were issued (with medical orders and physician's name intact). Others will not be accepted.
Only exact amount of medication is to be brought to camp.
Pills must be counted upon arrival in camp and upon termination of camp by parent and nurse. No medications other than those prescribed by a physician should be brought to camp. Do not pack medication(s) in suitcase. It must be given to the camp nurse at registration.

In the table below, mark (x) medications that participant may receive if deemed necessary and administered by the Camp Ohio nurse and/or attending physician:

_______	non-aspirin pain medication	_______	acetaminophen/Tylenol	_______	laxatives
_______	antacids	_______	antiseptics	_______	diarrhea medication
_______	Coriciden D	_______	Robitussin Cough Syrup	_______	adrenalin

List approximate date if participant has had or been exposed to:
Chicken Pox______________________________

Whooping Cough__________________________

Tuberculosis______________________________

Scarlet Fever_____________________________

Measles_________________________________

Mumps__________________________________

Date of last menstrual period____________________

Operations or serious injuries requiring medical treatment (specify):

__________________________________________________________________________________

Check below if participant is subject to:

Foods (specify):______________________________________________________________________

Medication, prescription or non-prescription drugs (specify):___________________________________

____________________________________________________________________________________________

Serious ivy, oak, or sumac poisoning:_________________

Bee or insect stings:_______________ Prescribed treatment:_________________________________

List all present medical and allergic conditions (contact lenses, braces, diabetes, etc.) which require medication, treatment, or special restrictions or considerations in participation.

Conditions:____________________________________________________________________________________

Medications:___________________________________________________________________________________

Specify any restrictions in activities:______________________________________________________

____________________________________________________________________________________________

Date of last tetanus shot:______________________ Date of last booster shot:___________________

I further understand in case of serious injury or illness I will be notified. If I cannot be contacted, I give my permission to the attending physician to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery for the participant as named above.

Parent/Guardian Signature_____________________________________________________________

Date____________________________________