HEARTS OF OHIO - State - Medical Information

MEDICAL INFORMATION - Due Sunday, May 31, 2026

ALL INFORMATION SUPPLIED IS STRICTLY CONFIDENTIAL.

PRIMARY EMERGENCY CONTACT INFORMATION

Parent/Guardian

Parent/Guardian Name

First NameLast Name

P/G Home Address

Street Address

Street Address Line 2

CityState

Zip Code

P/G Email Address

P/G Mobile Phone

Format: 000-000-0000.

P/G Home Phone

Format: 000-000-0000.

Alternate Parent/Guardian (optional)

Alternate Parent/Guardian Full Name (optional)

First NameLast Name

Alternate Parent/Guardian Address (optional)

Street Address

Street Address Line 2

CityState

Zip Code

Alternate Parent/Guardian E-mail Address (optional)

Alternate Parent/Guardian Cell Phone (optional)

Format: 000-000-0000.

Alternate Parent/Guardian Home Phone (optional)

Format: 000-000-0000.

HEARTS OF OHIO INFORMATION

Full Legal Name

First NameMiddle NameLast Name

Home Address

Street Address

Street Address Line 2

CityState

Zip Code

Birth Date

Date

Health Insurance Provider

Policy Number

Name of Insured

Family Physician

Family Physician Office Phone Number

HEALTH INFORMATION

Does your child have any physical limitations that might present a special problem, such as any health factor that may require them to follow a limited program of activities? If so, please indicate below.

Physical Limitations

Does your child have any serious or life threatening allergies, including food allergies, (i.e. bee stings, peanuts, dairy, allergies to medications)? If so, pelase indicate below.

Allergies

Please list all prescription medications your child will be taking while at Miss Ohio.
NOTE: All prescription medications must be in prescription original bottles from the pharmacy, appropriately labeled with the Physician’s name, the prescription name, dosage, and times to be taken. NO EXCEPTIONS.

Prescriptions

Please list all over-the-counter medications your child will be taking while at Miss Ohio.
NOTE: All OTC medications must be in their original packaging, with your child’s name WRITTEN on the bottle. Please do not send medications in alternate packaging.

Over the Counter Medication

All medications will be turned in to our Miss Ohio Contestant Chairperson upon arrival. The Chairperson will keep and distribute all medications and administer to your child as needed. The Chairperson is not responsible for mislabeled or incorrect usage or dosing instructions.

MEDICAL RELEASE

In the event of an emergency, Miss Ohio Scholarship Program has my permission to contact the Staff Doctor, Medic or 911, who will proceed as necessary. In case of serious injury or illness, my child can be transported to the Emergency Room, where they may proceed with treatment including but not limited to medications, injections, anesthesia, and surgery. Please list any conditions such as recent surgery, reoccurring or infrequent occurrences of mild allergies, hay fever, emotional problems, ADHD, etc.

Recent Information

Additional Info or Comments

You are welcome to submit any additional information or comments.

This health history is correct to the best of my knowledge, and the Hearts of Ohio Participant named has permission to engage in all activities unless otherwise noted.

Submitted By Name

Name of the person submitting this form

Submitted By Email

A copy of this form will be emailed to this E-mail Address