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.
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. Available Programming (Fall 2021)

     

44. Youth

    Ages 9-21 years old *Please select all programs you are interested in registering for* Class hours 3:00pm-6:00pm

    No programming September 6th and November 11th

46. Mondays

    1. Aug. 16th- Nov. 8th

    Various Activities and Sports 

47. Wednesdays

    1. Aug. 18th- Sep. 29th

    Kickball/ Boccee

48. Wednesdays

    1. Oct. 6th- Nov. 10th

    Bowling

50. Adults

    Adult Morning Program- Ages 22 and up *Please select all programs you are interested in registering for* Class hours 8:30am-11:30am

    Adult After Work Program- Ages 22 and up *Please select all programs you are interested in registering for* Class hours are 3:30pm-6:00pm

    *No programming September 6th and November 11th

52. Mondays

    1. Aug. 16th- Aug. 30th

    Adult Morning Program- Chair Yoga

53. Tuesdays

    1. Aug. 17th- Nov. 10th

    Adult Morning Program- Bowling (At Savannah Bowling Lanes 115 Tibet Ave.)

54. Wednesdays

    1. Aug. 18th- Nov. 10th

    Adult Morning Program- Chair Yoga w/ Fran, Exercise, Bingo and Life Skills

56. Thursdays

    1. Aug. 19th- Nov. 4th

    Adult Morning Program- Kickball/ Bocce (At Paulsen Softball Complex 7171 Skidaway Rd.)

57. Tuesdays

    1. Aug. 17th- Nov. 9th

    After Work Program- Basketball Skills and Conditioning/ Arts and Crafts at Jepson Museum

58. Thursdays

    1. Sept. 9th- Nov. 4th

    After Work Program- Kickball/ Bocce at Paulsen Softball Complex- 7171 Skidaway Rd./ Bowling at Savannah Bowling Lanes 115 Tibet Ave. 

62. 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.
63. 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
65. 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.
66. 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
68. 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.
69. Transportation Waiver*

    1. I AGREE, I have read and reviewed the Transportation Waiver
    2. I DO NOT AGREE. with the Transportation Waiver
71. 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.
72. 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
74. 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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76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit

* indicates a required field