Lessons from
Scott Patterson
Registration Form
(Please Complete this form and fax to
(404) 266-0063 or contact
Scott Patterson at (770) 715-0782)
Player’s First name: _____________________________
Player’s Last name : ________________________________
Date of Birth:
___/____/_____
Contact information:
Father’s Name: _______________________________________
Mother’s Name: ________________________________
Address: ________________________________________________________________________________________________
Phone: H ( ____)________________ W ( )________________ C ( )____________________
(Please check One)
Individual
_____ 1 session – 1 hour …………$65
_____ 5 sessions – 5 hours ……….$300 (save $25)
_____10 sessions – 10 hours……….$550 (save $100)
Group Training (2 players)
_____1 session $40 each
_____5 sessions $180 each
_____10 sessions $350 each
Circle payment type: Cash or Check (Make Checks Payable to Scott Patterson)
WAIVER OF
LIABILITY AND RELEASE
I recognize that there are inherent risks involved in sports and fitness
activities. In consideration of the services provided, I hereby release and
hold harmless, Scott Patterson (coach), his staff, Peachtree Road United Methodist Church (PRUMC)
and its Department of Sports, Recreation and Life Enrichment and its Directors,
employees, and agents
from any and
all liability for injuries, including those resulting in death, and
illnesses incurred while participating or attending any practice or any game.
By signing this document, the participant or legal guardian confirms that he or
she has authority to sign, has read the entire document, and has understanding
that the document waives certain rights of the person signing or the
participant.
Pease Print Name Clearly: ______________________________________________
Signature: __________________________________________Date:
_______________