PRUMC Sports Recreation & Life Enrichment:  Registration Form
Mail, drop off or email to:

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

3180 Peachtree Rd. Atlanta, GA 30305, email: charlesa@prumc.org
(Clear photographs accepted for email)

 

Season:  __________    Year:  _____ Sport/Activity:  _________________       Player___  Coach ___                                                                                                                                

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 preferences:  (Day/ Time/ Coach, etc): 
 _______________________________________________________________________________________

 

Credit Card Type:     Visa ___   MC___       AMEX____           Exp. Date:  ________CV Code: ________
 

 Card #:  _____________________________________________    Amount:  $_________________

 

Signature:  ________________________________________________________Date:  ____________

 
If participant is under 18, please complete below:

Fatherís Name:  ________________________________  Email:  ________________________________

Phone:  W (        )_____________________________C (        )__________________________________

Motherís Name:  ____________________________  Email:  ___________________________________

Phone:   W (        )_____________________________C (        )__________________________________
For the purpose of creating your family's account for on-line registration, please list the names of any additional family members:
____________________            _______________________            __________________________ 
Dates of Birth  _______                            ________                                        _________
 

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.

           

Print Name Clearly:   _________________________________________________

 

Signature: __________________________________________Date: _______________