PRUMC

Georgia Breakers Girls Basketball League - Team Roster
Please print (in Landscape) and mail, fax or drop off to Peachtree Road United Methodist Church Sports & Recreation
3180 Peachtree Road NE, Atlanta, GA 30305 (404) 266-2386, Fax-(404) 266-0063

Team Name: _____________________________

Coaches Name Address Phone Number Email Address

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Players Name Date of Birth Address Phone Number Email Address

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Circle payment type (Please Circle):   Cash     Check (pay to PRUMC)     Credit Card: Visa / MC

Amount:$1,200.00 Card/ Check #: ______________________________________ Exp. Date: _________

Cardholder Address (if applicable): _______________________________City__________ St____ Zip_______

Signature: ________________________________________________________Date: ____________

Insurance Liability Waiver must be signed for each player. Go Here: Waiver

Return to GA Breakers Information                  Return to PRUMC Sports and Recreation

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