Springboard Application

Emergency Form
Parent/Guardian #1
Name:*

First NameLast Name
Phone Number:*
Please enter a valid phone number.
Relationship to Youth:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
example@example.com

Youth Allergies and Administration of Medicines
Asthmatic:*

YesNo
Medical Condition:
Food Allergies*

YesNo
Please List down below.
Allergic reactions, signs or symptoms to look for:
Name of Medication:
All medications, prescription and over the counter, must be provided to the City of Antioch staff in their original packaging, with your child's full name written on the container. Remember to provide medication cups, spoons, or other instruments for the medication's administration. The medication dosage must be completed below in the INSTRUCTION section. If the additional instructions are required, please attatch another sheet.
Instructions: Parents/Guardians- Please write specific step-by-step instructions for staff to follow in the event your child has an allergic reaction or displays symptoms of a medical condition. You must confirm these steps with your child's physician or health care provider. By providing these instructions, you are consenting to staff's ASSISTANCE with medical treatment of your child.

For example:
1. Administer Epi-Pen
2. Administer 2 teaspoons of liquid Benadryl
3. Call 911
4. Call parents at---
Please List Below:

Medical Authorization
I authorize any City of Antioch employee to perform emergency procedures, including assisting with the administration of epi-pens, injections or self- administered medications (whether over the counter or prescription) or any other steps that I have described above to treat any illness, medical condition, allergic reaction, or injuy that my child may experience. I recognize and acknowledge that there are certain risks of injury in connection with administration of medication to any minor child. Such risks include, but are not limited to, failing to properly administer the medication, failing to observe side effects, failing to assess and recognize the adverse reaction, failing to assess and/or recognize a medical emergency, and failing to recognize the need to summon emergency medical services.

I hereby authorize City of Antioch employees or staff to assist in the administration of medication on my behalf or allow my child to self-administer (if permitted by my child's physician)the lawfully prescribed Epi-Pen or other medication in the event of an allergic reaction by my child. I acknowledge the assistance in administration of the Epi-Pen or other medication to my child by an individual who is not a nurse or medical professional may be necessary, and I specifically consent to such practice.

I hereby waive any claim for myself, my heirs, executors, assigns or personal representatives that I may have against the city of Antioch, its officals, officers, employees, agents or volunteers, from any and all claims for damages arising out of or in any way connected to the self-administration, assist-in administration, failure to administer or attempt to administr any medcation to my child.I further agree to protect, indemnify, defend and hold harmless the City of Antioch, its officials, officers, employees, agents, and volunteers, for any claims for damages, including attorney fees, arising out of or in any way connected to the self-administration, assist-in-administration, failure to administer or attempt to administer medication to my child. I also give my permission to the City of Antioch staff to contact emergency services or obtain emergency medical treatment if necessary. I agree to be wholly responsible to payment if any and all medical and emegcency services rendered to my child.
Signature of Youth ( 18 years or over):

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Date:

MonthDayYear
Date
Signature of Parent/Guardian:*

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Date:*

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Reminders:
- Participants are responsible for arriving at the program with all necessary medications, supplies, pumps, back-up medications and any other equipment necessary for the participant to safely self administer their medications.
- Medical monitoring of blood sugar levels must be done by parent or guardians prior to attending the program each day, to ensure that they are within their target range.
- Staff will not be responsible for identifying symptoms of hyperglycemia or hypoglycemia, but can assist the participant in checking blood sugar levels with proper training provided by parents or guardians.
- Parents/guardians are responsible for providing all necessary information regarding dietary restrictions, food allergies or special diet considerations to staff.
- Participants and parents/guardians shall be advised and reminded that it is the participants responsibility to administer the medication and that staff will only assist as needed. Staff will not give scheduled injections.
- It is the responsibility of the parent/guardian to pick up any medications that remains at the conclusion program. Any medication not picked up with be disposed of in a safe manner.
MUNICIPAL POOLING AUTHORITY 1911 SAN MIGUEL DRIVE· SUITE 200

· WALNUT CREEK, CA 94596 925) 943-1100

· FAX (925) 946-418

Media Release
I hereby authorize the City of Antioch, its affiliates, and their respective employees, agents, volunteers, and/or contractors (“City”) to photograph or otherwise record my likeness or that of the below-named individual under 18 years of age. I further grant the City the irrevocable, perpetual and unrestricted right and permission to, use, re-use, publish, and republish my likeness in photographs, pictures, videos or other medium in any and all of its publications, including, without limitation, web-based publications and social media and such other medium as the City may desire. I understand and agree that all photos, videos, or other medium featuring my likeness will become City property, and will not be returned. I hereby irrevocably authorize the City to edit, alter, copy, exhibit, publish, or distribute these photos, videos, or other medium for any lawful purpose. I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to royalties or other compensation arising or related to the use of the photos, videos, or other medium. I further irrevocably authorize the use of my likeness in conjunction with my own or a fictitious name, and in any and all media now or hereafter known for illustration, promotion, art, editorial, advertising, trade, public-service advertisements to promote the City, or any other lawful purpose. I hereby release, discharge, and agree to hold harmless the City from any liability related to this release, including, without limitation, any claims for defamation or violation of any right of publicity or privacy. This release constitutes a waiver of any and all rights under California Civil Code section 3344, and any related statutes. I hereby warrant that I am at least 18 years of age and have the right to contract in my own name, or, if I am under 18 years of age, I have obtained the required consent of my Parents/Guardians as evidenced by their signatures below. I have read the above authorization, release, and agreement, prior to its execution, and I am fully familiar with the contents of this document. This document shall be binding upon me and my heirs, legal representatives, and assigns.
Date:*

MonthDayYear
Date
Parents Signature:*

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Printed Name:*

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Monday
Tuesday
Wednesday
Thursday
Friday

Springboard Application

Participant Information

Emergency Form

Parent/Guardian #1

Youth Allergies and Administration of Medicines

Medical Authorization

Media Release

Essay:

Department/Divisions Descriptions: