Irvine, CA · Orange County
Emergency Form
Irvine Senior Services participants use this form to provide personal, emergency contact, physician, insurance, and medical information to the city.
What this form is
The Emergency Form collects personal information, primary and secondary emergency contacts, physician details, insurance coverage, medical information, medications, and advanced health care directive status. The signer can authorize City of Irvine staff to contact the listed person for additional information or in an emergency. It includes a signature field and space for office registration details.
Who needs it
Senior Services participants who want to provide the city with emergency contacts and medical information can complete this form.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
No notary is required; the signer authorizes staff by signing the form, and it lists no notarized or sworn attachment.
How to submit this form
- 1
Download the Form
Download the Emergency Form PDF.
- 2
Complete the Form
Fill in your personal information, emergency contacts, physician details, insurance coverage, and medical information.
- 3
Review and Sign
Review your entries and sign to authorize City of Irvine staff to contact the listed person.
- 4
Submit to the City
Submit it to the city department named on the form; check the city website for current contact details.
Frequently asked questions
- What information does the Emergency Form request?
- It asks for personal details, emergency contacts, physician and insurance information, medical information, medications, and advanced health care directive status.
- Who can use the Emergency Form?
- The form is for people providing information to Irvine Senior Services. It includes fields for personal details, emergency contacts, and medical information.
- Do I need a notary for the Emergency Form?
- No. The signer authorizes staff by signing the form; it lists no notarized or sworn attachment.
- How do I submit the Emergency Form?
- The form does not provide submission instructions. Submit it to the city department named on the form; check the city website for current contact details.
Need something notarized?
This Emergency Form doesn’t need a notary — but if you have another Irvine form that does, a commissioned online notary can help.