Form Center

Therapeutics Program Registration

2. City of Savannah Therapeutics Program Registration
   Note: Persons living outside of Savannah City Limits will be asked to complete a non-resident form. Please call 912.651.6791/92 for the non-resident form.

   Note: Persons living outside of Savannah City Limits will be asked to complete a non-resident form. Please call 912.651.6791/92 for the non-resident form.

4. • Youth: Ages 9-21 • Adults: Ages 22+ •

5. Select Application Type*

   1. Adult

   1. Youth

7. First Name

8. Last Name

10. Address1

12. Address2

14. City

15. State

16. Zip

18. Email*

19. Primary Phone Number*

20. Secondary Phone Number

21. Date of Birth*
    Date of Birth

23. Disability*

24. Additional Information

26. Do you use a wheelchair?*
    -- Select One --YesNo

27. Gender*
    -- Select One --MaleFemaleI prefer not to say

28. Race*
    -- Select One --American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteI prefer not to say

30. Employer/School Name*

31. Teacher's Full Name (Youth Only)

33. Employer/School Phone Number*

34. Transportation from EmployAbility/School?*
    -- Select One --YesNo

36. Emergency Contact*

37. Emergency Primary Phone Number*

38. Emergency Secondary Phone Number

42. Youth: Available Programming (SPRING 2020)
    Ages 9-21 | No Programming March 16 & 18 | *Please select all programs you are interested in registering for*

    Ages 9-21 | No Programming March 16 & 18 | *Please select all programs you are interested in registering for*

44. Monday • March 9 - May 4 • 3 - 6 p.m.

    1. Tennis Skills / Social Fun Club

    Various Locations

45. Wednesday • March 11 - May 6 • 3 - 6 p.m.

    1. Badminton/ Basketball Skills/ Creative Arts

    Pick-Up: John S. Delaware Community Center

47. Friday • March 27

    1. Annual Spring Fling Fun Day

    *Rain Date: Friday, April 3

48. May 26 - June 26 • 5 Weeks

    1. Summer Camp * MUST REGISTER WITH EASTER SEALS *

    Please register with Easter Seals. First come, first served. Limit 20 participants. Location TBD.

50. Adults: Available Programming (SPRING 2020)
    Ages 22+ | March 10 - May 5 | *Please select all that you are interested in*

    Ages 22+ | March 10 - May 5 | *Please select all that you are interested in*

52. Tuesdays • March 10 - May 5 • 3:30 - 6 p.m.

    1. Chair Yoga/ Volleyball/ Creative Arts

    Pick-up from John S. Delaware Community Center

53. Thursdays • March 12 - May 7 • 3:30 - 5:30 p.m.

    1. Bowling

    Pick-Up from Savannah Bowling Lanes • 115 Tibet Ave • 5:30 p.m.

55. Tuesdays • March 10 - May 5 • 3:30 - 5:45 p.m.

    1. Swimming * Special Olympics Swimmers Only

    New Member Try-Outs March 10 | Pick-up from Chatham County Aquatic Center • 7240 Sallie Mood Drive

56. Summer Activities

    1. Summer Camp | July 6 - July 31
    2. Summer Games | May 22 - 24
    3. Master's Bowling | August 14 - 16 | Warner Robins

60. 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 Therapeutics Recreation 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 Therapeutics Recreation 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 Therapeutics Recreation Program and participate in all programs and activities.

    I, as the above applicant and/or the legal guardian of minor child(ren) for whom I seek Therapeutics Recreation 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 Therapeutics Recreation 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 Therapeutics Recreation Program and participate in all programs and activities.

61. 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

63. 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.

    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.

64. 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

66. 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 Therapeutics Recreation Program. I hereby release and hold harmless the City of Savannah, the The Therapeutics Recreation Program, its agents, members, employees and any individuals involved in the planning, organization or presentation of Therapeutics Recreation 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 Therapeutics Recreation Program.

    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 Therapeutics Recreation Program. I hereby release and hold harmless the City of Savannah, the The Therapeutics Recreation Program, its agents, members, employees and any individuals involved in the planning, organization or presentation of Therapeutics Recreation 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 Therapeutics Recreation Program.

67. Transportation Waiver*

    1. I AGREE, I have read and reviewed the Transportation Waiver
    2. I DO NOT AGREE. with the Transportation Waiver

69. Internet and Equipment Use Policy
    The Therapeutics Recreation Program is pleased to offer participants access to its computers for the purpose of furthering the educational and career goals of its participants. The City of Savannah Therapeutics Recreation Program 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 Therapeutics Recreation Program is pleased to offer participants access to its computers for the purpose of furthering the educational and career goals of its participants. The City of Savannah Therapeutics Recreation Program 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.

70. Internet and Equipment Use Policy*

    1. I AGREE, I have read and reviewed the Internet and Equipment Use Policy
    2. I DO NOT AGREE with the Internet and Equipment Use Policy

72. 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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74. 1. Receive an email copy of this form.
75. Email address

    This field is not part of the form submission.

76. Submit

* indicates a required field