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
36. Emergency Contact*
37. Emergency Primary Phone Number*
38. Emergency Phone Number*
40. Authorized Adults for Participant's Pick-up
42. Name*
43. Number*
44. Name*
45. Number*

47. 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?

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

50. Does your child have any seizure disorder?

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

53. Has your child experienced seizures in the past?

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

56. 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?

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

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

60. Yes/No*
    -- Select One --YesNo
62. If you answered "Yes" to any of these medical questions, please explain:
66. Available Programming
68. Youth

    Youth Application
    Ages 9-22 years old *Please select all programs you are interested in registering for* 

    *Special Olympics Indoor Winter Games practices will be on Mondays until we leave for games*

70. Mondays

    1. January 9- February 27

    Table Tennis and Volleyball Skills

71. Wednesdays

    1. January 11- March 1

    SCAC- (Musical Movement / Arts and Crafts)

72. Both

    1. Monday and Wednesday Activities
76. Adult Morning Program

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

78. January 9- March 3

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

    Various Exercises, Tennis Skills, Flagged Football Skills, Arts & Crafts, Bingo & Line Dancing Skills

82. Adult Afterwork Program

    Adult Afternoon Application 
    Adult After Work Program- Ages 22 and up 

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

    *Special Olympic Indoor Winter games practices will be on Tuesdays and Thursdays until we leave for games*

    
    

84. Tuesday

    1. January 10- February 28

    Various Exercises and Arts and Crafts

85. Thursday

    1. January 12- March 2

    Table Tennis and Volleyball Development Skills

86. Both

    1. Tuesday & Thursday Activities
90. 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.

91. Initials:*
93. 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.

94. Initials*
96. 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.

97. Initials*
99. 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.

100. Initials*
102. 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.

103. Initials*
105. 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.

106. Initials*
108. 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.
Leave This Blank:


110. 1. Receive an email copy of this form.
111. Email address

     This field is not part of the form submission.

112. Submit

* indicates a required field