PRUMC Sports & Recreation: Fitness Boot Camp Registration Form

Please complete and submit with payment.

Season: _______________    Year: ______________    PRUMC Member? Yes_____   No _____

Name: __________________________________________________________   M _____  F_____

Email: ______________________________________ Date of Birth: ___ / ___ / _____   Age: _____

Address: ___________________________________________________________________________

City/State/Zip: _____________________________________________________________________

Phone: Home (        ) ________________  Work (       ) _______________  Cell (       ) ______________

Choose Class Time (circle one):

1) 5:55-7:05 am @ PRUMC                                                     4) 4:30-5:40 pm @ E. Rivers   

2) 8:20-9:30 am @ PRUMC & 7:25-8:25 am @ E. Rivers          5) 6:00-7:10 pm @ E. Rivers  

3) 9:35-10:45 am @ PRUMC

My goal in signing up for Fitness & Training Boot Camp is (check all that apply):

____ Increase Fitness          ____ Lose weight        ____ Run faster for the Peachtree Road Race      

____ Get out of the house     ____    other ____________________________________________

T-shirt size (circle one):

Small    Medium    Large    Extra-Large

Do you have any medical condition or pre-existing injury that we should know about?

__________________________________________________________________________________

Do you object to having a picture that includes you posted on our website for promotional purposes? ______ Yes  ______ No

Circle payment type:    Cash      Check       Credit Card (Visa/MC only)          Exp. Date: ___________

Card/Check # (make checks payable to PRUMC): ______________________________________________ _____  

Amount:    $250 for 6 weeks or $41.66 a week

(Please note that the registration fee is non-refundable. Forms received without payment will not be processed)

Signature: ___________________________________________________     Date: _____________________

If participant is under 18, please complete below:

Father's Name: _____________________________________   Phone: Work (        ) ____________________

Mother's Name: _____________________________________  Phone: Work (        ) ____________________

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, Peachtree Road United United Methodist Church 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 event or in any facility of Peachtree Road United Methodist Church. 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.

Print Name Clearly: ___________________________________________________________________

Signature: _____________________________________________________      Date: _____________

Peachtree Road United Methodist Church l Sports, Recreation, & Life Enrichment

3180 Peachtree Road NW, Atlanta GA 30305 l Phone: 404-266-2386 l Fax: 404-266-0063