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4-H Teen Conference Participant Health Form Mail this form to address below before June 17th

Participant Name:

Attendance Date:

______________________________________________________ First Middle Last

_____

June 26th028th, 2011

County____________________

State 4H Office WSU Pullman Nancy Mordhorst 323H Hulbert Hall PO Box 646248 Pullman, WA 991646248

Male

Female Birth Date (Month / Day / Year) _____________ Age on arrival:

____

To Parent(s)/Guardian(s): Please keep a copy for your records.

Participant Home Address:

________________________________________________________________________________________

Street Address

City

State

Zip Code

Parent/guardian with residential placement and/or decision-making authority in the event of illness or injury:

Name:___________________________________________________________

Relationship to Participant:

_____________________

Preferred Phones: (______) _______________

(______) ______________

Email:

________________________________

Home Address:

_________________________________________________________________________________________________

(If different from above)

Street Address

City

State

Zip Code

Second parent/guardian with legal responsibility/authority to be contacted in case of illness or injury:

Name:___________________________________________________________

Relationship to Participant:

_____________________

Preferred Phones: (______) _________________

(______) _______________

Allergies:

No known allergies. This participant is allergic to:

Food

Medicine

The environment (insect stings, hay fever, etc.)

Other

(list)

This participant has a life-threatening allergy. An emergency care plan signed by physician is required.

Please describe below, in detail, what the participant is allergic to, the reaction seen & any preventive or responsive measures

utilized (i.e. medications). Attach additional forms if necessary.

Immunizations:

My child is up-to-date on his/her immunizations and tetanus shots as required by Washington State law.

My child has an immunization exemption on file with his/her school. I understand and accept the risks to my child from not being fully immunized.

Medication:

Medication is any substance a person takes to maintain and/or improve their health. This includes all prescription medication, as well as all over-the counter drugs that are potentially hazardous if misused (e.g., Tylenol, aspirin, cough medicine, cold tablets, vitamins & natural remedies. All medications must be in their original containers. Prescriptions must have the child’s name and how the medication should be given printed on the prescription container. Please send only those medications that are necessary. Participants are required to turn medications into staff upon arrival.

This participant will not take any daily medications while attending the activities.

This participant will be self-administering the following daily medication(s) while attending the activities.

__________________________________________________________________________________

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