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Community Services

1 Civic Center Plaza Irvine, CA 92606


Form 54-52: Walk/Bike Parental Authorization and Release

My child has my permission to (check those which apply):

My child may walk/bike to the following location(s) FROM the PROGRAM:

My child may be signed out/in by staff upon departure/arrival:

My child may be signed out/in at their own discretion under this condition:

Days of week child will be walking/biking:


I understand the City of Irvine cannot assume responsibility for the safety and well-being of my child while outside of supervised care prior to arrival and/or after departure from the program. In consideration of accepting participant registration, I hereby release the City of Irvine and its officers, clients, agents, or employees from any and all manner of action or actions, cause or causes of action, in law or equity, suits, liabilities, claims, losses, costs or expenses (including attorney’s fees), of any kind of nature whatsoever, known or unknown, fixed or contingent, whether related to negligent or intentional acts of omissions or any other act or omission and whether related to bodily injury, property damage, or any other form of injury or loss to my self (and to any minor children for whom I have the capacity to contract). On behalf of myself and any minor children, I hereby indemnify and hold harmless the City of Irvine and its officers, clients, agents, or employees arising out of the participation in this program or other classes sponsored by the City, enrolled by the person(s) registered for a calendar year. I give permission to the City of Irvine to photograph me or my children participating in the programs for use in future City publicity and understand that I will not receive any compensation for such use. I recognize for myself and any minors, that the events and occurrences to which this release applies can be dangerous and as a result as signing below, I am accepting those risks for myself and any minor participants for whom I contract.

I certify that I have read and understand this waiver and release as it applies to myself and to any minors for whom I am signing.

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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.