Form E-13 - Participant Information And Authorization Form 2017 (Page 2 of 2) in pdf

Medical History and Authorization Information

My child experiences the following: Please CHECK ‘None’ or all that apply. Additional forms are required prior to your child

attending if medical conditions are checked. Providing this additional information will help us to ensure your child has a

positive experience

. Efforts will be made to provide reasonable accommodation in accordance with the Americans with Disabilities Act.

NONE

ADD

ADHD

Allergies

Currently taking

Medication at:

Asthma

Asperger’s Syndrome

Autism

Behavior Disorder

Program

Diabetes

History of Seizures

Hearing Impairment

Learning Disability

School

Mental Disability

Physical Disability

Dev. Disability

Visual Impairment

Home

Other: _________________________________________________________________________

Unless you have religious objections, we cannot allow your child to participate without the following authorizations. If you have religious

objections, please submit a written statement of those objections. A MEDICAL TREATMENT AUTHORIZATION Form signed by a physician is

required for any medication taken or administered while in a Seattle Parks and Recreation, Associated Recreation Council or Advisory Council

program. Forms are available at each facility.

Child’s Name (First & Last)

Age

Birth Date

Grade

Medical Provider (First & Last)

Dental Provider (First & Last)

Address, City, Zip Code

Phone

Date of Last Physical Exam:

Date of Last Dental Exam:

Month ______________

Year _____________

Month ______________

Year _____________

If you do not have a medical provider, in case of injury or incident,

If you do not have a dental provider, in case of injury or incident,

what is your plan:

Preferred Hospital for Treatment:

I authorize the administration of all medical, dental, and surgical examinations, operations, treatment, and all related care, including

emergency or ambulance transportation and the administration of drugs, tests, anesthesia and blood transfusions to the above-named

minor when a physician or dentist at the treating medical facility deems those procedures necessary for emergency treatment. I consent to

the release of medical report(s) to any doctor or agency and consent to the admission of the above-named minor person to the hospital. I

understand that the City of Seattle, its Department of Parks and Recreation, Associated Recreation Council, Advisory Councils, the

Community Center, and their officers, employees, and volunteers assume no financial obligation or liability in case of my child's accident or

illness. I assume full financial responsibility for emergency treatment for my child.

Initial Here _________

LEGAL DOCUMENTATION INFORMATION

Please complete the information below, that pertains to your child, regarding documentation relating to a parenting plan or a current

restraining order which has been issued by a legal authority and is in affect in the State of Washington:

ARENTING

LAN

ESTRAINING

RDER

 YES

 NO

 YES

 NO

Expiration Date: _____________

If yes, provide copy for child’s program file

PARENTAL CONSENT, RELEASE AND WAIVER OF LIABILITY,

ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

EVENT(S): All programs and activities offered by or through Seattle Parks and Recreation and Associated Recreation Council including

but not limited to recreation activities and classes, school age care, preschool, teen programs, special events, field trips, sports, and ath-

IN CONSIDERATION of my minor child (“the Minor”) being permitted to participate in any way in the EVENT(S), I agree:

I know the nature of the EVENT(S) and the Minor’s experience and capabilities, and believe the Minor to be qualified to participate in the

Event(s). The Minor and I will inspect the premises, facilities, and equipment to be used or with which the Minor may come in contact to

ensure it is safe to our satisfaction. I have spoken with the Minor about the dangers of the activities and the fact that the Minor could—for

a variety of known, unknown, foreseeable and unforeseeable reasons, including negligence of the City of Seattle, its employees and

volunteers, officers and agents—be seriously injured. In extreme cases, such injuries could include permanent disability, paralysis or even

death (“risks”). Even understanding these risks I consent to the Minor’s participation in the Event(s) and assert that the Minor is willing to

participate in the event.

I accept and assume all risks, and assume all responsibility for the losses, costs and/or damages following an injury related to the Event(s),

including disability, paralysis or death, even if caused in whole or in part by the negligence of the following releasees: the City of Seattle, its

employees and volunteers, officers and agents. My acceptance of these risks includes releasing and agreeing not to sue the releasees. I

also agree to indemnify and save and hold harmless the releasees and each of them from any and all litigation expenses, attorney fees,

loss, liability, damage, or cost they may incur due to a claim made against any of the releasees identified above based on an injury to the

Minor, whether the claim is based on the negligence of the releasees or otherwise and whether the claim is made by me, is made on

behalf of the minor, or is otherwise made.

_________________________________

________________________________

____________________________

Signature of Parent or Guardian

Printed Name of Parent or Guardian

Date

Form E-13 - Participant Information And Authorization Form 2017 Page 2

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