Virginia Cooperative Extension

Virginia Tech • Virginia State University

4-H Adult Health
History Report Form

Publication 4H-224
2013-2014

INSTRUCTIONS: Please provide information concerning your health for participation in 4-H Events for the current year. If you are a person with a disability and desire any assistive devices, services, or other accommodations to participate in activity, please contact your local Extension office during business hours at least 7 days prior to the event to discuss accommodations. PLEASE PRINT ALL INFORMATION. (NOTE: Both sides of this form must be completed.)

COUNTY ________________________________________________________________

IDENTIFICATION

NAME ________________________________________________________________ FEMALE MALE

Last

First

MI

MAILING ADDRESS ________________________________________________________________ CELL PHONE (____) ____________________

CITY ________________________________________________________________ STATE ____________________ ZIP ____________________

HOME PHONE (____) ____________________ BIRTHDATE ____________________ EMAIL ________________________________________________________________

EMERGENCY CONTACT

NAME ________________________________________________________________ CELL PHONE (____) ____________________

ADDRESS ________________________________________________________________ HOME PHONE (____) ____________________

RELATIONSHIP ________________________________________________________________ WORK PHONE (____) ____________________

PHYSICIAN/INSURANCE INFORMATION

NAME OF PHYSICIAN ________________________________________________________________ PHONE (____) ____________________

MEDICAL/HOSPITAL INSURANCE ________________________________________________________________

Carrier

Policy ID #

MEDIA RELEASE

The Virginia Polytechnic Institute and State University/College of Agriculture and Life Sciences (CALS) periodically uses electronic and traditional media (e.g., photographs, video, audio footage, testimonials) for publicity and educational purposes. By my signature on this form, I acknowledge receipt of this document and give permission to the College of Agriculture and Life Sciences and its designee to use such reproductions for educational and publicity purposes in perpetuity without further consideration from me.

I understand that I will need to notify Virginia Tech/College of Agriculture and Life Sciences if any changes to my situation occur that will impact this media release permission.

PLEASE INITIAL
YES _________________________ NO _________________________

www.ext.vt.edu

*18 USC 707

Produced by Communications and Marketing, College of Agriculture and Life Sciences, Virginia Polytechnic Institute and State University, 2014

Virginia Cooperative Extension programs and employment are open to all, regardless of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, genetic information, marital, family, or veteran status, or any other basis protected by law. An equal opportunity/affirmative action employer. Issued in furtherance of Cooperative Extension work, Virginia Polytechnic Institute and State University, Virginia State University, and the U.S. Department of Agriculture cooperating. Edwin J. Jones, Director, Virginia Cooperative Extension, Virginia Tech, Blacksburg; Jewel E. Hairston, Administrator, 1890 Extension Program, Virginia State, Petersburg.

VT/0114/4H-224