Georgia 4-H Medical Information Release FormGeorgia 4-H Medical Information Release Form
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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 unders