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Get Adult Medical Form - Uc Cooperative Extension

DER) This Treatment Authorization Form is authorized for all 4-H Youth Development meetings and activities during the dates specified below. (Please Note: This information must be updated annually) First Name Last Name Club/Unit Name From: July 1, 2014 to December 31, 2015 County and State While I am attending or traveling to or from this 4-H function, I HEREBY AUTHORIZE THE ADULT 4-H VOLUNTEER OR 4-H STAFF MEMBER, or in his/her absence or disability, any adult accompanying or assisting him/.

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