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Community Services

yourirvine@cityofirvine.org

1 Civic Center Plaza
Irvine, CA 92606

949-724-6610

Form Section 1

Participant Emergency Form


Medical and emergency treatment information is provided on this form. This is for use by City of Irvine staff only. All information provided has been obtained by the parent or guardian of the child/participant. This form should be kept with the program staff at all times when child/participant is registered.


PARTICIPANT INFORMATION


ALLERGIES


MEDICAL CONDITIONS


EMERGENCY CONTACTS

It is imperative that program staff have emergency phone numbers to contact a relative/friend at any time during program hours. I authorize the following person(s) to pick up my child in my absence:

ACKNOWLEDGMENT

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

  • I have completed the City of Irvine Emergency Form (EFORM);
  • I have completed the City of Irvine Emergency Medical Data Sheet;
  • I have explained the Emergency Medical Data Sheet with program staff responsible for participant prior to the first program/class/activity meeting;
  • I have reviewed administration of medicine documented on Medicine Log and Administration with program staff responsible for participant prior to the first program/class/activity meeting;
  • I have provided non-expired medicine 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.


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.