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2. CREATIVE ARTS PROGRAM REGISTRATION
4. First Name
5. Last Name
7. Email*
8. Phone Number*
9. Birthday*
   Birthday
11. Address1
13. Address2
15. City
16. State
17. Zip
19. Parent/Guardian Name*
20. Primary Contact Number*
21. Secondary Contact Number
23. School Name*
24. Grade*
26. Gender*
    -- Select One --MaleFemaleI prefer not to say
27. Race*
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteI prefer not to say
28. Do you have special needs?
    -- Select One --YesNo
29. If yes, please explain.
31. Emergency Contact (Other than parent/guardian)*
32. Emergency Contact Primary Phone Number*
36. 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 Creative Arts Program Registration, 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 Creative Arts Program, 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 Creative Arts Program and participate in all programs and activities. Each day that my child chooses to attend the creative arts sessions, I understand that he/she must remain in the area set aside for the class and will not be released until the end of class unless I pick up my child or send a note to say that the child is to be released at an earlier time and into whose care.
37. Assumption of Risk, Waiver of Liability, and Indemnification*

    1. I AGREE, and have 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
39. Photo/Media Release
    I hereby grant permission to the Therapeutics Recreation Program 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 Therapeutics Recreation Program, 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.
40. Photo/Media Release*

    1. I AGREE, I have read and reviewed the Photo/Media Release
    2. I DO NOT AGREE, to the Photo/Media Release
42. Transportation Waiver
    I authorize the City of Savannah to transport or otherwise provide transportation for myself/my child by public service bus, private automobile, vans or other appropriate means of transportation in connection with the Creative Arts Program. I hereby release and hold harmless the City of Savannah, the Creative Arts Program, its agents, members, employees and any individuals involved in the planning, organization or presentation of Creative Arts events and activities, which involve transportation, for any accident, injury, illness or any damage whatsoever related to the above mentioned participation in any activity or session of the City of Savannah Creative Arts Program.
43. Transportation Waiver*

    1. I AGREE, I have read and reviewed the Transportation Waiver
    2. I DO NOT AGREE. with the Transportation Waiver
45. Signature of Parent/Legal Guardian*
    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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47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field