| 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: |
| ________________________________________________________________________________________ |
| ________________________________________________________________________________________ |
| Immunization Record |
| Please record the date (month & year of basic immunizations and most recent booster doses. |
| Vaccines | Year of Basic Immunization | Year of Last Booster |
| Diphtheria
Pertussis (whopping cough) DPT* Tetanus or |
1
2 3 |
1
2
|
| Tetanus
TD*
Diphtheria or |
|
|
| Tetanus | ||
| Oral Polio (Sabin)* TOPV | ||
| Injectable Polio (Salk) | ||
| Measles (hard measles, red measles, Rubeola) | ||
| Mumps | ||
| Rubella (German measles, 3-day measles) | ||
| Other | ||
| Tuberculin test given (most recent) | ||
| Hemophilus influenza b (HIB) |
| PARENT/GUARDIAN MEDICAL RELEASE |
| _________________________________________________ has my permission to participate in the Ohio 4-H program and activities (with the exception of those restricted activities listed). I understand participants will be supervised. I understand the 4-H staff and volunteers, Ohio State University Extension and The Ohio State University are not responsible in the event of accidental injury or illness, nor for the compounded injury or illness to the participant's present medical conditions listed. 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. |
| Signature ____________________________________ | Date _______________________________________ |
| All education programs and activities conducted by Ohio State University Extension are available to all potential clientele on a nondiscriminatory basis without regard to race, color, creed, religion, sexual orientation, national origin, sex, age, handicap or Vietnam-era veteran status. |
| Issued in furtherance of Cooperative Extension work, Acts of May 8 and June 30, 1914, in cooperation with the U.S. Department of Agriculture, Keith L. Smith, Director Ohio State University Extension. |