TEXAS 4-H CENTER
ADULT HEATH HISTORY FORM
Complete the entire form and bring with you to the Texas 4-H Center. This form will be turned in with any
medication you bring, both prescription and non-prescription, to the health room upon your arrival.
Date of Birth _______________ Age ________
City ________________________________ State _______
Physical Limitations or Handicaps ____________________________________________________________________________________________________
SPECIAL or PRESCRIPTION MEDICATIONS
are being taken.
If YES, list the name of the drug(s) and/or medication, along with the name and phone number of the prescribing physician, dosage,
“over the counter” medications which camp personnel may administer as deemed necessary:
____ Motrin (Ibuprofen) ____ Pepto Bismol
Special Dietary Needs or Conditions:
(i.e. Food Allergies, Diabetes, etc.) If notified in advance, the Center is happy to
(Please check any of the following that apply)
Operations or Serious Injuries (List along with approximate
Chronic or Recurring Illness: ____________________________________________________________________________________________
Name of Family Physician: ___________________________________________
Medical Insurance Carrier: ___________________________________________
Date of last Tetanus Immunization: ___________________________________________
The Health History is correct as far as I know. Authorization for Treatment:
In the event that I become incapacitated, I
hereby give permission to have emergency first aid administered by any qualified person in case of illness and/or injuryand to be transported by the most expedient means of conveyance to the nearest available physician, hospital or clinicand to there receive treatment as is medically prescribed by physician(s). In case of extreme illness and/or injury, I dofurther agree that the Texas Cooperative Extension, the Texas 4-H Youth Development Foundation and their employeesor agents, individually or collectively, shall not be held responsible or liable for personal injury or loss resulting on thepremises of the Texas 4-H Center.
The Texas 4-H Center considers this privileged information. It will be used for medical reasons only.
WAIVER & RELEASE OF CLAIMS and
(with Authorization For Medical Care)
This authorization covers during his/her travel to and participation in __________
, a 4-H event. This activity covers the period through .
I, _______________________), understand that participation in the activities that make up this event is not withoutsome inherent risk of injury. In consideration of participant’s involvement in this event, I hereby release, waive,
discharge, and covenant not to sue the sponsor of this event, the State of Texas, The Texas A&M University System,the Board of Regents of the System, Texas A&M University, the Texas Cooperative Extension, the Texas 4-H & Youth
Development Program, or any employees or agents of these entities (releasees/indemnities), from any and allliability, claims, or causes of action whatsoever arising out of or related to any loss or injury, including death, that
may be sustained by participant, including claims arising from the negligence of releasees. I further agree to defend,hold harmless and indemnify indemnitees from any and all claims and causes of action as a result of participant’s
involvement and actions at this event, including claims and causes of action arising from the negligence ofindemnitees. The foregoing agreements are effective while traveling to and from the event, and while participatingin the event and on premises where the activity is being conducted.
I give my permission for participant to be treated for condition requiring emergency medical care, as determinedby a health care professional, and accept responsibility for the cost of the treatment. I agree to defend, holdharmless and indemnify indemnitees for any expenses incurred in treating participant. In case of sudden illness oraccident to participant, either at the event or traveling to or returning from the event, I authorize Texas Cooperative
Extension personnel serving as chaperones to take reasonable action to protect the health and physical well-beingof participant. I understand a medical policy carried by American Income Life, if any, may be available to paycertain medical expenses related to treatment of participant. The following information is provided as an aid to thechaperones in dealing with the well-being of participant.
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