2021 Participant Permission and Medical Data Form

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Please CLICK HERE to complete the current 2022 Participant Permission and Medical Data Form.

If you have a moment, please let us know how you found this page by sending an email to yourirvine@cityofirvine.org and telling us where you found the link to this page. This will help us fix the links for others. Thank you!

Oops! You have reached an out-of-date form.

Please CLICK HERE to complete the current 2022 Participant Permission and Medical Data Form.

Please only submit ONE new form per child, per calendar year. If your child's information changes during the calendar year, submit additional information using the "UPDATE" option below.

After submitting this form, you will see a link to submit forms for additional children in your household.

The medical and emergency treatment information provided on this form is for use by City of Irvine staff.

Please make sure to also update your family's emergency contact information at yourirvine.org.

Are you completing a NEW form for the calendar year 2021 or an UPDATE to a form submitted after February 15, 2021?

NEW

UPDATE

Oops! You have reached an out-of-date form.

Please CLICK HERE to complete the current 2022 Participant Permission and Medical Data Form.

Family Information

PRIMARY CONTACT NAME (FIRST & LAST)

RELATIONSHIP TO PARTICIPANT

PHONE

CONTACT EMAIL ADDRESS

ALTERNATIVE CONTACT (FIRST & LAST)

RELATIONSHIP TO PARTICIPANT

PHONE

Participant Information

CHILD'S NAME (FIRST & LAST)

Please note any updates to your child's allergies or medical conditions that you would like staff to be aware of.

DATE OF BIRTH

SCHOOL

DOES YOUR CHILD HAVE AN ALLERGY OR MEDICAL CONDITION?

Please note your child's known allergies and medical conditions, including the method of contact that will cause an allergic reaction and medical condition symptoms.

Does your child need to take medication while in the care of the City of Irvine, or take medication that may affect their ability to participate in the programs?

Please note the medication needed during the program or that may affect your child's participation. Please include any allergy medication, such as Epi-pen.

Is there any other information you would like to share about your child, such as environmental control measures, dietary restrictions or other information that staff should know?

ACKNOWLEDGMENT/CONSENT FOR TREATMENT

If you have selected "yes" above to indicate that your child may require medicine to be administered while participating in an activity, your signature below acknowledges:

I understand that I, the parent/guardian of (PARTICIPANT), am responsible to ensure that:

I have explained the information provided in the Participant Medical and Allergy Data Form with program staff responsible for participant prior to the first program/class/activity meeting;
I have reviewed administration of medicine documented with program staff responsible for participant prior to the first program/class/activity meeting;
I have provided non-expired medicine (if outlined on this Participant Medical and Allergy Data Form) to the Community Services Department or to participant to carry at all times while registered in the City program.

I, the undersigned, parent/guardian of (PARTICIPANT), allow the City of Irvine staff to possess medication and provide to (PARTICIPANT) for administration.

I allow the City of Irvine Staff to administer medicine in the case of an emergency or event that it is required by my child/participant.

I, on behalf of myself and my child and our heirs, successors and assigns, agree to hold harmless, release, indemnify, and defend the City, and its respective officers, employees, agents, representatives, sponsors, volunteers, successors, and assigns from any and all liabilities, losses, damages, claims, costs, demands or causes of action arising out of or related to my child's participation in the program(s) howsoever caused, whether caused by action or active or passive negligence and whether caused by City, my child or any other individual or entity.

By signing this form, you will waive certain rights ON BEHALF OF YOURSELF AND YOUR CHILD. Please read carefully.

In the event of injury, the City of Irvine (“City”) has my consent to secure medical treatment for my child. I understand and acknowledge that I will be responsible for payment of all medical services rendered, including reimbursement to the City for any medical expenses incurred in the care of my child.

The City has my consent to photograph me and/or my child participating in the programs for use in future City publicity. I understand and acknowledge that my child and I will not receive compensation for such use.

The City has my consent to take my child on offsite excursions under the supervision of the City. I understand and acknowledge that modes of transportation for offsite excursions may include, without limitation, City vehicles, vehicles under contract with the City or walking to local sites.

I, on behalf of myself and my child, understand and acknowledge that participation in the programs may involve the risk of serious injury which may result not only from my child’s actions, but also from the actions, inactions or negligence of others, the condition of the facilities, equipment or areas where the program is being conducted, or the nature of the program itself. I, on behalf of myself and my child, understand and acknowledge that my child is voluntarily participating in the program(s) with knowledge of the danger involved, and agree to accept and assume any and all risks of personal injury, wrongful death, property damage or other loss from participation in the programs and/or activities.

I, on behalf of myself and my child and our heirs, successors and assigns, agree to hold harmless, release, indemnify, and defend the City, and its respective officers, employees, agents, representatives, sponsors, volunteers, successors, and assigns from any and all liabilities, losses, damages, claims, costs, demands or causes of action arising out of or related to my child’s participation in the program(s), howsoever caused, whether caused by action, inaction or active or passive negligence, and whether caused by the City, my child or any other individual or entity.

I HAVE CAREFULLY READ THIS WAIVER, RELEASE OF LIABILITY, AND ASSUMPTION OF RISK AGREEMENT AND UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS DOCUMENT RELIEVES THE CITY AND OTHERS FROM LIABILITY FOR PERSONAL INJURY, WRONGFUL DEATH AND PROPERTY DAMAGE, AND, ON BEHALF OF MYSELF AND MY CHILD, SIGN IT VOLUNTARILY.

Sign Here for Acknowledgement/Consent for Treatment

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.

The City of Irvine takes your privacy seriously. This form asks you to provide the City with certain personal information. Such information is being requested and will be utilized by the City for the specific and limited purpose of future City correspondence regarding the subject-matter of this form. Pursuant to Measure S, an initiative ordinance passed by City voters in 2008, all information provided on this form will be kept confidential. Unless you expressly indicate to us otherwise or unless compelled by a court order, it will not be shared with other agencies, businesses or individuals.