California Youth Medical Release FormCalifornia Youth Medical Release Form
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University of California Division of Agriculture and Natural Resources
4-H Youth Development Program

Youth Medical Release Form
This Medical Release Form is authorized for all 4-H Youth Development meetings and activities during the dates specified below:
_________________________________________________ _______________________________________________
First Name
Last Name
Club/Unit Name
_________________________________________________ ______________________ to _______________________
County and State
Dates (From / To)
While my child is attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE ADULT 4-H VOLUNTEER LEADER OR 4-H
STAFF MEMBER, or in his/her absence or disability, any adult accompanying or assisting him/her, TO CONSENT TO THE FOLLOWING
Any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under
the general or special supervisio