Form Center

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/Ethnicity*
    -- 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
35. Participant Pick up From School
    -- Select One --YesNo
37. Emergency Contact*
38. Emergency Primary Phone Number*
39. Emergency Phone Number*
41. Authorized Adults for Participant's Pick-up
43. Name*
44. Number*
45. Name*
46. Number*

48. All Pick-Ups will be from Delaware Center, please return applications by Wednesday, March 1, 2023. 

50. Does your child suffer from any disorder or medical condition that may impede or interfere with his/her ability to participate in any physical activity, including swimming safely?

51. Yes/No*
    -- Select One --YesNo

53. Does your child have any seizure disorder?

54. Yes/No*
    -- Select One --YesNo

56. Has your child experienced seizures in the past?

57. Yes/No*
    -- Select One --YesNo

59. Is your child presently under the care of a physician for any disorder or medical condition of which the City should be aware to ensure his/her safe participation in physical activities?

60. Yes/No*
    -- Select One --YesNo

62. Does your child take any medications or have any other special needs (including allergies)?

63. Yes/No*
    -- Select One --YesNo
65. If you answered "Yes" to any of these medical questions, please explain:
69. Available Programming
71. Youth

    Youth Application(registration deadline is Monday, December 11th at 12:00 noon)
    MUST BE Ages 9-22 YEARS OLD TO PARTICIPATE (Still in High School)

    MONDAY, JANUARY 15, 2024 ~ MLK JR. HOLIDAY - NO PROGRAMMING

    TUESDAY, FEBRUARY 20, 2024 ~PRESIDENT'S DAY - NO PROGRAMMING 

73. Mondays

    1. January 8 - February 26

    Exercises & Developmental Ball Skills

74. Wednesdays

    1. January 10 - February 28

    SCAC

75. Make a Selection

    1. Mondays
    2. Wednesdays
    3. Both
77. Quick Facts

    · Priority placement is given to City of Savannah residents. Non-residents will be placed on a waiting list and contacted when a vacancy becomes available.

    · Registrations should be made as soon as possible. Space is limited and filled on a first come, first served basis.

    · The City reserves the right to refuse enrollment to participants with a history of unacceptable behavior.

    · Pick up is at 5:45pm on Mondays and Wednesdays.

    General Information:

    Parents/Caregivers must sign participant in and out each time the participant is picked up. 

    COVID-19:  I/We understand COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact and participating in City of Savannah programs and accessing City facilities could increase the risk of contracting COVID-19. The City in no way warrants that contracting COVID-19 or other contagions will not occur through participation and use of City programs/facilities.

     Parental Consent:  I give my permission for my child, or client to participate in the Recreation & Leisure Services Therapeutic Program. I hereby release the Recreation & Leisure Services, City of Savannah, and its representatives of any obligation in the event of an accident or injury.  I will allow my child (client) to be photographed or videotaped for the purpose of communicating the objectives and activities of the Recreation & Leisure Services Department.

81. Adult Morning Program

    Adult Morning Application(Adult Registration deadline is Monday, December 11th at 12:00pm).

    Adult Morning Program- Ages 22 and up *Please select all programs you are interested in registering for* 

83. Daily Classes: January 8 - March 1

    Morning Chair Yoga, Social Session (w/coffee & snacks), Arts & Crafts, Bingo(prizes), Basketball Development Skills & Other Skills and Fun Fridays!

    JANUARY 15 MLK JR. HOLIDAY – NO PROGRAMMING

    FEBRUARY 19 PRESIDENT’S DAY HOLIDAY – NO PROGRAMMING

85. Check Days You Will Attend

    1. Mondays Only
    2. Tuesdays Only
    3. Wednesdays Only
    4. Thursdays Only
    5. Fridays Only
    6. Daily

    QUICK FACTS:

    • Priority placement is given to City of Savannah residents. Non-residents will be placed on a waiting list and contacted when a vacancy becomes available.
    • Registrations should be made as soon as possible. Space is limited and filled on a first come, first serve basis. 
    • The City reserves the right to refuse enrollment to participants with a history of unacceptable behavior.
    • Pick up time is at 10:45am Monday - Thursday. Pick up time on Friday is 11:30am.

    
    

89. Adult Afterwork Program

    Adult Afternoon Application (Adult Registration deadline is Monday, December 11th at 12:00pm)
    Adult After Work Program- Ages 22 and up to participate.  

    *Please select all programs you are interested in registering for* 

    
    

91. Tuesdays

    1. January 9 - February 27

    Various Exercises & Free Play

92. Thursdays

    1. January 11 - February 29

    BINGO & Developmental Ball Skills

93. Make Your Selection

    1. Tuesdays Only
    2. Thursdays Only
    3. Both

95. Quick Facts:

    · Priority placement is given to City of Savannah residents. Non-residents will be placed on a waiting list and contacted when a vacancy becomes available.

    · Registrations should be made as soon as possible. Space is limited and filled on a first come, first served basis.

    · The City reserves the right to refuse enrollment to participants with a history of unacceptable behavior.

    · Pick up is at 5:45pm on Tuesdays and Thursdays

    JANUARY 15 MLK JR. HOLIDAY – NO PROGRAMMING

    FEBRUARY 19 PRESIDENT’S DAY HOLIDAY – NO PROGRAMMING

    UPCOMING EVENT: SPECIAL OLYMPIC INDOOR WINTER GAMES JANUARY 2024*

99. Statement of Consent, Risk, Waiver of Liability, and Indemnification

    I, as the above primary applicant and as the legal guardian of minor child(ren) list for whom I seek Recreation and Leisure Services membership, hereby knowingly, voluntarily agree, and understand, as part of myself and/or family members listed, incidents may occur and inherent risks may be exposed, including the risk of serious physical injuries (included but not limited to disability and death, as well as economic and property loss). I further realize and understand that participating in this membership may involve risks and dangers, both known and unknown; therefore, I have elected to allow myself and/or family members listed to participate in these services and activities.

100. Initials:*
102. Internet and Equipment Use

     Recreation and Leisure Services will always promote the opportunity for the member to utilize its computer for purposes, offer access to exercise equipment and other technological equipment to extend educational, fitness, and career goals to members; Recreation and Leisure Services will not be responsible for any information that is lost or property that is damaged or stolen. Recreation and Leisure Services do not control the content of information available on the internet. Therefore, parents should be advised that youth members will have access to worldwide information and may encounter inaccurate, offensive, or otherwise objectionable material. Members are not permitted to use the internet, center computers, equipment, supplies, or other objects to cause harm to themselves or others. Damages to Recreation and Leisure Services property due to misuse/mishandling shall be the responsibility of the member and/or primary member/guardian. Recreation and Leisure services reserve the right to monitor any and all use of equipment, including internet access.

103. Initials*
105. Photo/Video and any other Marketing Release

     I, as the above primary applicant and as the legal guardian of the minor child(ren), grant permission to Recreation and Leisure Services and/or representatives the right to use, edit, reproduce, assign, and modify and distribute photographs, film, video/audio recordings and any other audio/visual productions for the use in public displays, publications, public relations, slide shows, newspaper, advertising, and any other communications for the purpose of visual sharing. I insure and hold harmless the City of Savannah, Recreation and Leisure Services, its officers, employees, sponsors, and volunteers from and against any and all claims of any kind, which included all compensation and any liabilities arising from or related to the use of photographs and/or recordings and medial releases.

106. Initials*
108. 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 Therapeutic 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 participation mentioned above in any activity or session of the City of Savannah Therapeutic Recreation Program.

109. Initials*
111. COVID-19 Release

      I/We understand COVID-19 is a highly contagious virus that spreads quickly through person-to-person contact. Participating in Recreation and Leisure Services programs and accessing City facilities could increase the risk of contracting COVID-19. The City in no way warrants that contracting COVID-19 or other contagions will not occur through participation and use of City programs/facilities.

112. Initials*
114. Statement of Medical Consent

     In the event of an emergency resulting in medical treatment, I, the primary applicant and/or the legal guardian of the minor child(ren) for whom I request Recreation and Leisure Services membership, do hereby give permission and consent for medical attention to be administered to myself and/or al family members listed on the application as part of my membership agreement application, including but not limited to; utilization of ambulatory care, first aid, AED if available and any other equipment or treatment to assist in the emergency.

115. Initials*
117. Disciplinary Action

     We at the City of Savannah, Recreation & Leisure Services, Therapeutics Department want to ensure that all staff and participants stay safe while enjoying each activity, field trip, event and having fun. With that being said, we have set a few disciplinary guidelines that will be followed to guarantee just that. Please note that this guideline does not list all offensive behaviors and should be used as a reference.

     Minor Offense

     Examples of offenses include, but are not limited to: 

     1. Walking away from group (But not putting self in danger)
     2. Being disrespectful to staff and/or peers, I.E., talking back
     3. Switching seats on a moving vehicle 

     Disciplinary Action:  

     *Countdown (Used to let participants correct action before staff reaches final number)

     *2-3 verbal warnings    

     *Timeout (10–15-minute break from activity and/or group)       

     *Parent conference     

      * 1–2-day suspension.

     Moderate Offense

     Examples of offenses include, but are not limited to:

     1. Hitting peers and/or staff
     2. Constantly using foul and/or offensive language
     3. Bullying and/or instigating peers

     Disciplinary Action: 

     2-3 verbal warnings        

     *Timeout (10–15-minute break from activity and/or group)    

     *Parent conference   

     *2-3 day suspension

     Major Offense  

     Examples of offenses include, but are not limited to:

     1. Fighting
     2. Attempting to harm self or others
     3. Damaging property

     Disciplinary Action: 

     *One week suspension    

     * Two-week suspension     

     *Self-reflection time at home for  remainder of the program

119. Rules and Guidelines for Adult Morning and After work Program

     ´Participants will be scheduled from a waiting list on a first come/first serve basis when classes are filled and as space becomes available.

     ´

     ´     Please notify the staff if your child will be unable to attend for two or more days in order to be kept on roll.  You will be notified that your child /client  has been taken off the roll.

     ´

     ´     Participants must be to center no later than 3:45pm and must be picked up by 5:45pm.   Repeated offenses may cause the participant to be dropped from the program.

     ´

     ´      Please notify Therapeutic staff if you have any problems or concerns in our programming.  We will do our best to alleviate the situation.

     ´

     ´      All parents/caregivers/guardians must sign participant in program by contacting Therapeutic staff .  If any participant is not signed in by staff, you will be called to pick up the participant.   If this happens more than one time, the participant will be dropped from the program.  Please remember that COMMUNICATION  is key in our partnership.

     ´

     ´If you have any concerns or an emergency, please contact staff at 547-1164 or 651-6791 office or the main office at 351-3841. 

121. Care Givers

     If your participant is co-dependent, i.e., unable to complete basic task of daily living or needs one-on-one support, and/or also considered to be a “runner”, please be sure to provide a caregiver when your participant is in attendance. 

     All caregivers are welcome to attend field trips as well. 

      

     *Runner: an individual who leaves designated area without permission and normally does not come back when prompted at least twice.  

123. Quick Facts

     Recreation & Leisure Services Administrative Office (Daffin Park) is located at 1301 E. Victory Drive Savannah, GA 31404 Phone: 912-351-3841

     
     

     • Priority placement is given to City of Savannah residents. Non-residents will be placed on a waiting list and contacted when a vacancy becomes available.
     • Registrations should be made as soon as possible. Space is limited and filled on a first come, first serve basis. 
     • The City reserves the right to refuse enrollment to participants with a history of unacceptable behavior.

     Pick up time is at 5:45pm on Mondays and Wednesdays

125. 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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127. 1. Receive an email copy of this form.
128. Email address

     This field is not part of the form submission.

129. Submit

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