Form Center

2. Pennsylvania Avenue Resource Center Membership Application
4. Membership Type:*

   1. Adult Only
   2. Family Membership
5. Today's Date*
   Today's Date
7. Basic Information (Primary Applicant)
9. First Name*
10. Last Name*
12. Address*
14. Address
16. City*
17. State*
18. Zip Code*
20. Home Phone
21. Cell Phone*
22. Email
24. Gender*
    -- Select One --MaleFemaleI prefer not to say
25. Date of Birth*
    Date of Birth
26. Do you have children?*
    -- Select One --YesNo
27. If yes, how many?
29. Are you currently employed?*
    -- Select One --YesNoRetired
30. If yes, what is your occupation?
32. What is your ethnicity?*

    Please select all that apply.

    1. African American/Black
    2. Alaska Native
    3. American Indian
    4. Asian

    1. Caucasian/White
    2. Pacific Islander
    3. Other
    4. I prefer not to say
33. What is your highest level of education?
    -- Select One --Grade School - 1st GradeGrade School - 2nd GradeGrade School - 3rd GradeGrade School - 4th GradeGrade School - 5th GradeGrade School - 6th GradeGrade School - 7th GradeGrade School - 8th GradeHigh School - 9th GradeHigh School - 10th GradeHigh School - 11th GradeHigh School - 12th GradeGED CertificateHigh School DiplomaCollege - 1 yearCollege - 2 yearsCollege - 3 yearsCollege - 4 yearsAssociates DegreeBachelors DegreeMasters DegreeDoctorate Degree
34. Please check the box that represents your household income:*
    -- Select One --$0 - $9,999$10,000 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$60,000+
38. Basic Information (Secondary Applicant)
40. First Name
41. Last Name
43. Address (if different than above)
45. Address
47. City
48. State
49. Zip
51. Home Phone
52. Cell Phone
53. E-Mail Address
55. Gender
    -- Select One --FemaleMaleI prefer not to say
56. Date of Birth
    Date of Birth
57. Do you have children?
    -- Select One --YesNo
58. If yes, how many?
60. Are you currently employed?
    -- Select One --YesNoRetired
61. If yes, what is your occupation?
63. What is your ethnicity?

    Please select all that apply.

    1. African American/Black
    2. Alaska Native
    3. American Indian
    4. Asian

    1. Caucasian/White
    2. Pacific Islander
    3. Other
    4. I prefer not to say
64. What is your highest level of education?
    -- Select One --Grade School - 1st GradeGrade School - 2nd GradeGrade School - 3rd GradeGrade School - 4th GradeGrade School - 5th GradeGrade School - 6th GradeGrade School - 7th GradeGrade School - 8th GradeHigh School - 9th GradeHigh School - 10th GradeHigh School - 11th GradeHigh School - 12th GradeGED CertificateHigh School DiplomaCollege - 1 yearCollege - 2 yearsCollege - 3 yearsCollege - 4 yearsAssociates DegreeBachelors DegreeMasters DegreeDoctorate Degree
68. #1 Youth Information
70. First Name
71. Last Name
73. Address (if different than above)
75. Address
77. City
78. State
79. Zip
81. Home Phone
82. Cell Phone
83. E-Mail Address
85. Gender
    -- Select One --FemaleMaleI prefer not to say
86. Age
87. Date of Birth
    Date of Birth
89. School Name
90. Grade
92. Any past incidents resulting in:

    Please check all that apply

    1. Arrest
    2. Not Applicable

    1. Expulsion

    1. School Suspension

    1. Conviction
94. If yes, please explain incident
96. *Please note, structured PARC youth after school programming is limited to middle school and high school students.
100. #2 Youth Information
102. First Name
103. Last Name
105. Address (if different than above)
107. Address
109. City
110. State
111. Zip
113. Home Phone
114. Cell Phone
115. E-Mail Address
117. Gender
     -- Select One --FemaleMaleI prefer not to say
118. Age
119. Date of Birth
     Date of Birth
121. School Name
122. Grade
124. Any past incidents resulting in:

     Please check all that apply

     1. Arrest
     2. Not Applicable

     1. Expulsion

     1. School Suspension

     1. Conviction
126. If yes, please explain incident
130. #3 Youth Information
132. First Name
133. Last Name
135. Address (if different than above)
137. Address
139. City
140. State
141. Zip
143. Home Phone
144. Cell Phone
145. E-Mail Address
147. Gender
     -- Select One --FemaleMaleI prefer not to say
148. Age
149. Date of Birth
     Date of Birth
151. School Name
152. Grade
154. Any past incidents resulting in:

     Please check all that apply

     1. Arrest
     2. Not Applicable

     1. Expulsion

     1. School Suspension

     1. Conviction
156. If yes, please explain incident
160. #4 Youth Information
162. First Name
163. Last Name
165. Address (if different than above)
167. Address
169. City
170. State
171. Zip
173. Home Phone
174. Cell Phone
175. E-Mail Address
177. Gender
     -- Select One --FemaleMaleI prefer not to say
178. Age
179. Date of Birth
     Date of Birth
181. School Name
182. Grade
184. Any past incidents resulting in:

     Please check all that apply

     1. Arrest
     2. Not Applicable

     1. Expulsion

     1. School Suspension

     1. Conviction
186. If yes, please explain incident
190. Emergency Medical Information
192. Physician's Name:
193. Phone Number
194. Preferred Hospital
196. Insurance Carrier
197. Policy Number
199. Policy Holder's Name
200. Group Number
202. Are there any medications or medical concerns we should know of?
     -- Select One --YesNo
203. If yes, please explain:
205. Emergency Contact*
206. Emergency Contact Phone Number*
208. Statement of Medical Consent
     In the event of an emergency or non-emergency situation requiring medical treatment, I give permission and consent for medical attention to be administered to myself and/or family members listed as part of my PARC membership application, including but not limited to the administration of first aid, the use of an ambulance; the administration of anesthesia, and/or surgery under the care of qualified medical personnel. I also assume the responsibility for the payment of any such treatment.
209. Statement of Medical Consent*

     1. I AGREE with the Statement of Medical Consent
     2. I DO NOT AGREE with the Statement of Medical Consent
213. Assumption of Risk, Waiver of Liability, and Indemnification
     I, as the above applicant and/or the legal guardian of minor child(ren) for whom I seek PARC membership, do hereby knowingly and voluntarily agree, on behalf of myself and my children, their heirs, successors and assigns, to assume responsibility for all risks of loss, damage, or injury, (including but not limited to disability and/or death). I release, hold harmless, indemnify and forever give up any claim and demands of whatever nature, either in law or equity, against the City of Savannah, its Executive Officers, Board of Directors, employees, agents, sponsors, representatives and volunteers, of liability for any and all bodily injury (including but not limited to disability and/or death), property damage, and/or any other loss whatsoever which may arise out of, resulting from, or being associated with my own or my child(ren’s) use of, presence at, or participation in the PARC center, its property and equipment, and any of its programs on or off-site. I hereby certify that I fully understand and acknowledge said risks and responsibilities to myself and my children and hereby grant permission for my child(ren) to use the PARC and participate in center programs and activities. Internet
214. Assumption of Risk, Waiver of Liability, and Indemnification*

     1. I AGREE, I have read and reviewed the Assumption of Risk, Waiver of Liability, and Indemnification
     2. I DO NOT agree with the Assumption of Risk, Waiver of Liability, and Indemnification
216. Internet & Equipment Use Policy
     The PARC is pleased to offer members’ access to its computers, professional culinary and other technologically advanced equipment for the purpose of furthering the educational and career goals of its members. The PARC will not be responsible for: any information that is lost or property that is damaged or unavailable due to difficulties encountered by using center computers, equipment or the internet; any damages or costs arising directly or indirectly from member activities; for the accuracy or appropriateness of information found on the Internet; or any unauthorized, inappropriate or illegal use of equipment or information by you or your child. The PARC does not control the content of information available on the internet, and parents should be advised that youth members will have access to information worldwide and therefore may come into contact with material that is inaccurate, offensive or otherwise objectionable. Members are not permitted to use the Internet, Center computers, equipment, supplies or other training tools to do harm to themselves or others or to record or access sexually explicit, pornographic, vulgar or otherwise distasteful and/or negative materials from the Internet. Personal attacks on others or language which is defamatory, obscene, abusive, profane (swearing), threatening or discriminatory will not be tolerated. There is no expressed or implied right to privacy regarding the use of the Center’s computers, recording/training equipment or the Internet by members or others. Damages to PARC property resulting from the use/handling of Center property shall be the responsibility of the member and/or parent/guardian in the case of youth members. The PARC reserves the right to monitor any and all use of its computers, equipment and internet access. Members determined to be in violation of this policy may lose access privileges, Center membership, and/or face legal action. Any information gathered can be copied, reviewed, and stored and shall remain the property of the PARC.
217. Internet & Equipment Use Policy*

     1. I AGREE, I have read and reviewed the Internet & Equipment Use Policy
     2. I DO NOT AGREE with the Internet & Equipment Use Policy
219. Photo/Media Release
     I hereby grant permission to the PARC and/or agents acting on its behalf, the right to use, edit, reproduce, assign and distribute photographs, films, video/audio recordings and other audio/visual productions of myself and/or my child(ren) for use in public displays, publications, public relations, slide shows, newspapers, advertising and other communications, to include transmission via film, print, video, computer, worldwide web, internet website, email, FTP, computer network and digital reproduction and distribution. I indemnify and hold harmless the City of Savannah PARC, its officers, employees, sponsors and volunteers (the “indemnified parties”) from and against any and all claims of any kind, including royalties or other compensation, and any liabilities arising from or related to the use of the photographs or recordings.
220. Photo/Media Release*

     1. I AGREE, I have read and reviewed the Photo/Media Release
     2. I DO NOT AGREE with the Photo/Media Release
222. Parent Responsibilities & General Transport Release
     The parent/guardian is responsible for providing and/or coordinating transportation for his/her child on a daily basis. Membership termination may result from recurring failure to ensure adequate transportation of your child. There will be occasions upon which PARC Youth Members will be transported by the PARC to and from events, field trips, and other educational and cultural activities. Permission slips must be signed by parents/guardians in order for Youth Members to attend these activities. Any youth of driving age who transports him/herself in a personal vehicle to/from a sanctioned activity is not considered to be in the care of the PARC.
223. Parent Responsibilities & General Transport Release*

     1. I AGREE, I have read and reviewed the Parent Responsibilities & General Transport Release
     2. I DO NOT AGREE with the Parent Responsibilities & General Transport Release
227. Signature*
     I have agreed to submit this application by electronic means. My typed name in the box above will act as an electronic signature. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. By signing this application I agree that my answers are correct and complete to the best of my knowledge.
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229. 1. Receive an email copy of this form.
230. Email address

     This field is not part of the form submission.

231. Submit

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