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

Participant First Name:

Participant Last Name:

Parent/Guardian Name (First and Last):

Relationship to Child:

Home Phone:

Work Phone:

Address:

City:

State

Zip:

My child (participant listed above), has permission to walk/bike to/from the following PROGRAM, as noted below (choose PROGRAM):

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

Walk/bike to PROGRAM and be signed in by staff upon arrival

Walk/Bike from PROGRAM

Be signed out/in by staff upon departure/arrival

My child may walk/bike from the following location(s) TO the PROGRAM:

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

Home

Other

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

For specific activity outside of PROGRAM

When met to depart with a sibling or other under 18 years of age

At my child's own desire/discretion.

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

At any time

At specific time

Anticipated time of child's arrival to, or departure from PROGRAM:

School:

Days of week child will be walking/biking:

Monday

Tuesday

Wednesday

Thursday

Friday

Any

PARENT PERMISSION – RELEASE AND WAIVER OF LIABILITY AND INDEMNIFY AGREEMENT

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.

Sign Here

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.