Please mail, fax or drop-off:

Peachtree Road United Methodist Church Sports, Recreation and Life Enrichment

3180 Peachtree Road NE, Atlanta, GA 30305, (404) 266-2386, Fax-(404) 266-0063

Name of activity/class/sport: _________________________________________

Name: ________________________________ PRUMC Member? Y___ N___

M ____ F____ Email:__________________________ D.O.B ____/____/___

Address: ________________________________________________________

City: ___________________________ State: __________ Zip: _____________

Home phone: (____)________________ Work phone: (____)_______________

Specify Preference for Day/Time: ____________________________________

(for adult activities & classes only)

Payment Type: Cash/Check/ Credit Card (Visa/MC) Exp. Date_____________

(please circle one)

Check/Card # ____________________________ $ Amount___________

Signature____________________________________Date_________

Office use only: Date: ______ Paid $ ______ Check # ______ Due: $_____

I recognize that there are inherent risks involved in these activities. In consideration of the services provided, I hereby release and hold harmless, Peachtree Road 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.

Participant Name: _______________________________________

Signature: ________________________________________Date_________