2. High Hopes Program
   The High Hopes Program is a social and recreational program designed for adult’s ages 18+ with special needs. High Hopes program fosters socialization and community engagement through a variety of activities such as Dances, Karaoke, Bowling, Movie Night, and more. To become a member of this program, please complete this application. ACTIVITIES ARE $3 PP (UNLESS NOTED) AND OPEN TO ADULTS AGE 18+
4. Member Information
8. First Name*
9. Last Name*
11. Date of Birth*
12. Age*
13. Sex*

    1. Male
    2. Female
15. Address*
17. City*
18. State*
19. Zip Code*
21. Phone Number*
22. Alt Phone Number
24. Parent/Guardian/Caregiver Information (Emergency Contact)
28. First Name*
29. Last Name*
31. Phone Number*
32. Alt Phone Number
34. Program Agreement
    • Proper respect shall be given to participants and staff members at all times. • Participants who require functional needs assistance must be accompanied by a caregiver. • Participants who are sick are encouraged to stay home. • City staff are not permitted to administer medications. • Participants with behavioral needs must be accompanied by a caregiver. • Participants who engage in inappropriate or unlawful behavior will be subject to suspension and/or expulsion of the program. • Participants are required to stay within the physical boundaries of the facility during program hours. • Please inquire from within, to make any special requests. Staff make every effort to provide reasonable accommodations.
36. Photo/Video Release Consent*
    -- Select One --I hereby give my permission to use my image in City promotional materialI hereby do not give my permission to use my image in City promotional material
38. By selecting "I Agree" below, you acknowledge the following statement: “I certify that the above information is true and correct. I realize every precaution is taken to eliminate any injuries or hazards, and a competent supervisor is present; however, in the event of any injury, property damage, disability, death, sickness, or disease, I hereby waive, release and hold harmless from any liability for damages for personal injury including accidental death, sickness, or disease, as well as from claims for property damage which may arise in connection with the above named activity, the City of Temecula, its officers, agents, employees, volunteers and independent contractors. In case of accident or other emergency, personnel of the Community Services Department and/or its agents or independent contractors are hereby authorized to secure medical care deemed necessary as a result of accident or injury for the participant. I further agree to pay any and all costs incurred as a result of said treatment. I further permit the use of activity/event photography and/or video for media promotion."*
    -- Select One --I Agree
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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