PRUMC Sports Recreation & Life Enrichment:  Registration Form

Season:  __________    Year:  _______ Sport/Activity:  _________________       Player   /      Coach

                                                                                                                                  (circle one )

New to our programs?   Yes  /  No        If no, is there new contact information?    Yes   /   No

Name:  ____________________________________________    PRUMC Member?  Yes_____   No _____

 M ____  F ____   Email:  __________________________________Age:  _____   Birth date:  ___/___/___

 Address:  _____________________________________________________________________________

City/State/Zip:  __________________________________________________________________________________

School:  _______________________________________________________________________________________

Phone:  H (         )________________   W (         )________________   C (        )____________________

Specify one preference:  Day/ Time/ Coach: 

_____________________________________________________________________________

(no guarantees)

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

(Circle One Above)

Card/ Check #:  _____________________________________________    Amount:  _________________

(please note: forms received without payment will not be processed) (Checks payable to PRUMC)

Signature:  ________________________________________________________Date:  ____________

If participant is under 18, please complete below:

Father’s Name:  ________________________________  Email:  ________________________________

Phone:  W (        )_____________________________C (        )__________________________________

Mother’s Name:  ____________________________  Email:  ___________________________________

Phone:   W (        )_____________________________C (        )__________________________________

WAIVER OF LIABILITY AND RELEASE

I recognize that there are inherent risks involved in sports and fitness activities.  In consideration of the services provided, Ihereby 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.

Print Name Clearly:   _________________________________________________

Signature: __________________________________________Date: _______________

Peachtree Road united Methodist Church – Sports, Recreation and Life Enrichment

3180 Peachtree Rd. Atlanta, GA 30305, (404) 266-2386, facs: (404) 266-0063, email: cakin@prumc.org