Form E-13 - Participant Information And Authorization Form 2017
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1
22017 PARTICIPANT INFORMATION AND
Facility/Program:
AUTHORIZATION FORM
______________________________________________
This information is considered confidential and is used only to help staff meet the needs of your child. Please fill out all
sections completely (mark N/A if a section does not apply) and sign and initial where indicated. Additional
information may be required, including but not limited to immunization records, medical treatment, medication
administration instructions and authorization, and special field trip permission. If you have updated information on
this form, please contact staff immediately to update.
Participant and Parent Information
Child’s Name (First & Last)
Age
Birth Date
Male
Female
Address
City
ZIP
School
Grade
Parent/Guardian Name (First & Last)
Signature
Day Phone
Cell Phone/Pager
Evening Phone
E-mail
Address (if different than above)
City
ZIP
Language(s) Spoken at Home
Relationship to Child
Parent
Guardian
Foster Parent
General Authorizations and Information
No
Yes – Location: _________________________________
My child has attended a Seattle Parks School Age Care Program.
My child has permission to participate in field trips including, but not limited to, visits to a local library or park, neighborhood walk, or other
YES
NO Initial Here ______
field trip as posted, by means of walking, public bus, Dept van, yellow bus.
My child has permission to participate in swimming and other water activities at Seattle Parks and Recreation facilities, including swimming
YES
NO Initial Here ______
pools, lifeguarded beaches, boating facilities, and wading pools.
Non Swimmer
Beginner
Intermediate
Advanced
Swimming Ability:
YES
NO Initial Here ______
My child may apply sunscreen ___________ times during the day. I will provide sunscreen.
My child may be photographed (stills and video) for the City of Seattle, its Department of Parks and Recreation, the Associated Recreation
YES
NO Initial Here ______
Council, Advisory Council, or Community Center publications.
My child has the following behavioral issues which staff should be
I handle these behaviors in the following way:
aware: __________________________________________________
_______________________________________________________
________________________________________________________
_______________________________________________________
Emergency Contacts
(Also authorized for participant pick-up)
The Parent/Guardian named above will be contacted first in case of emergency (after 911). Please list additional parents,
guardians, and others you would like us to contact if we cannot reach you.
1) Contact Name (First & Last)
Relationship
Day Phone
Cell Phone/Pager
Evening Phone
E-mail
Address
City
ZIP
2) Contact Name (First & Last)
Relationship
Day Phone
Cell Phone/Pager
Evening Phone
E-mail
Address
City
ZIP
Pick-up Authorization and Information (Minimum Age 14)
Please list all individuals who are authorized to pick up your child. Individuals listed must be at least 14 years old. If an individual
is not listed, your child will not be released. We will not accept voice authorization for pick-up.
1) Name
Relationship
Day Phone
Evening Phone
Address
2) Name
Relationship
Day Phone
Evening Phone
Address
3) Name
Relationship
Day Phone
Evening Phone
Address
Child Sign In and Sign Out Procedures
The parent or other person listed above authorized by the parent to take the child to and from the center/program site shall sign in the child
on arrival and sign out the child at departure using a full, legal signature. When the child leaves the center/program site to attend school or
other off-site activities as authorized by the parent, the staff person shall sign out the child and sign in the child upon return to the center/
program. (WAC 170-297-2125)
E-13
(Supplemental Forms: B-41, B-42, Forms A-F)
(Rev. 1/9/2016)
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