PRUMC Sports Recreation & Life
Enrichment: Registration Form
Please print and mail/fax to:
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
Season: __________ Year: _______ Sport/Activity: _________________ Player___ Coach ___
Name:
____________________________________________ PRUMC
Member? Yes_____ No _____
M
____ F ____ Email:
__________________________________Age: _____ Birth
date: ___/___/___
Address:
_____________________________________________________________________________
(no guarantees)
Circle payment
type: Cash___ Check ___ Visa ___
MC___ Exp.
Date: ________________
Card/ Check #:
_____________________________________________ Amount:
_________________
3 Digit Security Code ______
(please note: forms received without payment will not be processed) (Make 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
( )__________________________________
For the purpose of creating your family's account for on-line registration,
please list the names of any addition family members:
____________________ _______________________ __________________________
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 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.