Form Center

2. Childs First Name*
3. Childs Last Name*
5. Select Center*
   -- Select One --Hudson Hill Community CenterCrusaders Community Center
7. Address*
9. City
10. State
11. Zip
13. Home Phone
14. Cell Phone
15. E-Mail Address
17. Age*
18. Date of Birth*
    Date of Birth
20. Parent / Guardian First Name*
21. Parent / Guardian Last Name*
23. Email*
24. Phone Number*
26. Address1
28. Address2
30. City
31. State
32. Zip
34. Permission to participate*

    1. I have reviewed the permission to participate and consent
    2. I have reviewed the permission to participate and do NOT consent
35. Permission to participate
    I/we, the undersigned, consent for me, my/our minor child/ward to participate in the programs sponsored by the City of Savannah. In consideration of me, my/our child’s/ward’s participation in the program I/we hereby agree(s) to assume all the risks and hazards incidental to said participation and do further agree(s) to release, absolve, indemnify and otherwise hold harmless the City of Savannah, its employees, administrators, agents and assigns and others who assist the above, for any loss, damages or personal injuries that I, said child/ ward may receive as a result of such participation. I/we hereby agree(s) to waive all claims against the City of Savannah, its employees, administrators, and agents.
37. Photo Release*

    1. I have reviewed the photo release and consent
    2. I have reviewed the photo release and do NOT consent
38. Photo Release
    I hereby grant permission to the City of Savannah Department of Cultural Resources 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 Department of Cultural Resources, 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. Medical Consent*

    1. I have reviewed the medical consent and give my consent
    2. I have reviewed the medical consent and do NOT consent
41. Medical Consent
    Please list below any medical conditions, (including allergies), or other special needs concerning the participant. I/we understand that there are some risks inherent in the activities that are included in the Program, but willingly assume these risks in order to allow me/my child/ward to participate. I/we give permission for any emergency medical care or treatment by a physician, surgeon, nurse, and doctor’s assistant, or medical care facility that may be required and assume responsibility for the cost of medical care.
43. Medical Conditions

    Please list any medical conditions you or your child have above.

Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

* indicates a required field