Therapeutic Recreation Services
Participant Registration Form 2015
FOR OFFICE USE ONLY
Program
Fee
Cash
Chk
Check #
Receipt Number
Date Received
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Participant Information
Name of Participant:
DOB:
Last
First
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M.I.
Address:
Street Address
Apartment/Unit #
City
Phone: (
)
State
ZIP Code
E-mail Address:
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Does participant live in the City of Chattanooga?
YES
If no which county/area:
NO
Name of Parent/Guardian (if under 18 years of age):
Last
Are you a veteran?
YES
First
M.I.
NO
Medical Information
Please provide us with the most current and thorough information pertaining to participant:
PLEASE CHECK ALL THAT APPLY:
ADD/ADHD
Allergies
Bowel/Bladder Catheter
Catheter
Colostomy Bag
Other:
Multiple Sclerosis
Muscular Dystrophy
Specify:
Cerebral Palsy
Post Traumatic Stress Disorder
Arthritis
Cognitive/Intellectual Disability
Spina Bifida
Asperger’s Syndrome
Diabetes
Spinal Cord Injury
Asthma
Down Syndrome
Injury Level:
Autism
Epilepsy/Seizure Disorder
Stroke
Describe:
Type:
Traumatic Brain Injury
Behavioral Health Needs
Hearing Impairment
Describe:
Bi-Polar Disorder
Partial
Frequency:
Total
Heart Condition
Visual Impairment
Partial
Total
OTHER:
Describe:
Please describe further details of any of the “checked” conditions above, including behavior needs, accommodations and/or additional
medical information:
Therapeutic Recreation Services
Participant Registration Form 2015
Mobility:
Ambulatory
Uses Walker
Uses Wheelchair
Braces/AFO
Cane
Other:
Allergies:
Please list all medications participant is currently taking:
Additional Information:
Emergency Contact
Name:
Primary Phone: (
Relationship:
Alternative Phone: (
Name:
Primary Phone: (
Relationship:
Alternative Phone: (
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)
Home
Cell
Work
Home
Cell
Work
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Medical and Media Release
In this section, you will be required to enter a digital signature which will be binding as your actual
signature. Your electronic signature below indicates your agreement with the following
Medical Release and Media Release Statements:
Permission is herby granted for myself/son/daughter/ward, named above, to participate in the activities associated with the
Therapeutic Recreation Program. I understand that these activities will be supervised by employees and/or volunteers of the
City of Chattanooga Youth and Family Development Department. As Parent/Guardian/Participant, I hereby release from liability
from injury incurred by myself/son/daughter/ward; and, I agree to indemnify and hold harmless, the following parties:
Chattanooga Youth and Family Development, City of Chattanooga and the respective and collected elected and appointed
officers, community partners (including, but not limited to: Creative Discovery Museum, The Little Gym, SPARC, DS-USA, US Youth Soccer,
Sunshine Ambassadors, Redoubt Soccer Complex, Chattanooga Zoo, Sunshine Ambassadors, US Paralympic Committee, and all other partners involved with
the City of Chattanooga’s Therapeutic Recreation Services )
employees, agents and servants of said parties from all claims, demands and
judgments arising out of myself/son/daughter/ward during participation in such an activity. I hereby authorize the City of
Chattanooga Youth and Family Development Department representative permission to seek medical treatment for myself/my
child should any emergency situation occur during participation in the Therapeutic Recreation program.
Medical Release: By placing my signature below, I certify that I have read this form and the terms and conditions set forth herein; and I
agree to abide by said conditions and terms, and certify that all information in this form is true, current and correct and may be relied upon by
the Therapeutic Recreation Program Personnel.
Participant Name:
Date:
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Parent/Guardian Name (if under18):
By typing my name on the following Signature line, I certify that I agree to the terms explained in the Medical Release above.
Participant/Parent/Guardian/Signature:
I, the undersigned, give permission for the use of photographs or images of myself/son/daughter/ward by any newspaper, City of Chattanooga
Representative or other publication. These photographs or images will be used for the sole purpose of promoting or reporting on the
Chattanooga Youth and Family Development Department’s Therapeutic Recreation Services Division.
Media Release By placing my signature below, I hereby authorize and give my full consent to the City of Chattanooga’s
Therapeutic Recreation services to copyright and/or publish any and all photographs, videotapes and/or film in which
myself/son/daughter/ward appears while attending this Therapeutic Recreation Services event. I further agree that Therapeutic
Recreation Services may transfer, use or cause to be used, these photographs, videotapes, or films for any exhibitions, public
displays, publications, commercials, art and advertising purposes, and television programs without limitations or reservations
Participant Name:
Date:
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Parent/Guardian Name (if under18):
By typing my name on the following Signature line, I certify that I agree to the terms explained in the Media Release above.
Participant/Parent/Guardian/Signature:
Therapeutic Recreation Services
1254 East Third Street,
Chattanooga, TN 37404