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Explain |  |  |  |  |  |  |  |  | Date |\n| Physical Impairment? Explain |  |  |  |  |  |  |  |  | Date |\n| Mental Health Issues Requiring Treatment? Explain |  |  |  |  |  |  |  |  | Date |\n| Current Medications and conditions for which they are prescribed? |  |  |  |  |  |  |  |  | Date |\n| Is there any other personal medical history you feel we should know? |  |  |  |  |  |  |  |  | Date |\n| Parent/Guardian Authorizations: |  |  |  |  |  |  |  |  |  |\n| I recognize that some activities have an inherent risk that could result in personal injury. The person herein described has permission to engage in all 4-H activities except as noted. Please list here: |  |  |  |  |  |  |  |  |  |\n| During the program, I hereby give permission for the Program Staff to administer appropriate medical attention to my child/ward in the event of any accident, illness, or injury, including non-prescription medications or any medications my child brings in original containers with dosage instructions that is provided to program staff. In the event of an emergency, 911 will be called and I will be responsible for any and all costs of medical coverage and treatment provided not covered by my child’s insurance. |  |  |  |  |  |  |  |  |  |\n| Insurance Provider: |  | Insurance Policy Number: |  |  |  |  |  |  |  |\n| Signature of parent or guardian |  |  |  |  |  |  |  |  | Date |\n| Printed Name |  |  |  |  |  |  |  |  | Date |\n|  |  |  |  |  |  |  |  |  |  |\n\n(Please Print)  \nOVER  \n\n| Consent for Medication Administration |\n| --- |\n| If your child or ward will be under the age of 18 while in attendance at 4-H, it is the University of Connecticut 4-H program policy to secure your consent for medication distribution and for the use of medical devices. The medication or medical device can be selfadministered or be administered by the on-site professional staff.\u003Cbr>All medications must be in a medicine bottle and labeled with the participant’s name, doctor’s name and phone number, medication name, and dosage.\u003Cbr>It is the parent’s responsibility to contact the 4-H volunteer or professional staff to make them aware of any medication that will need tobe administered during the program. You must complete the form below.\u003Cbr>  No medication will be brought to 4-H.\u003Cbr>  I want the medication or medical devices self-administered (Doctors note required for youth 13 and under) .\u003Cbr>  I want the medication or medical devise administered by the on-site program provider. However, a limited amount of medication for life threatening conditions may be carried by my child or ward. (i.e. bee sting kits, inhalers) |\n| Name of medication(s) Prescribing Doctor Doctor’s phone number |\n| Amount t","cbCaidfXKFIRE2Hv","https://ap.wps.com/l/cbCaidfXKFIRE2Hv","pdf",166421,"English","# Member/Volunteer Information\n## Emergency Contacts\n## Allergies and Medical Risks\n## Personal Medical History\n# Parent/Guardian Authorizations\n## Participation Permission\n## Medical Attention Permission\n## Insurance and Signatures\n# Consent for Medication Administration\n## Medication Storage and Labeling Requirements\n## Medication Details and Instructions","[{\"question\":\"What information is required in the Member/Volunteer section?\",\"answer\":\"The form requests participant name, sex, date of birth, and contact details such as street address, city/state/ZIP, and phone numbers.\"},{\"question\":\"How does the form handle emergency situations?\",\"answer\":\"It authorizes notifying listed emergency contacts and gives permission for program staff to administer appropriate medical attention, with 911 called in emergencies.\"},{\"question\":\"What must parents/guardians complete for medication administration consent?\",\"answer\":\"They must specify medication(s), prescribing doctor and phone number, dosage details, how and when it is taken, special instructions, and provide the required signature and date.\"}]","4-H Member/Volunteer Health Form - Updated 1/6/23 | PDF",1789483532]