PRUMC Sports Recreation & Life
Enrichment: Registration Form
Mail, drop off or email to:
Peachtree Road united Methodist Church – 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 ___
Name:
____________________________________________ PRUMC
Member? Yes_____ No _____
M
____ F ____ Email:
__________________________________Age: _____ Birth
date: ___/___/___
Address:
_____________________________________________________________________________
Credit Card Type:
Visa ___ MC___ AMEX____
Exp. Date: ________________
Card #: _____________________________________________ Amount: $_________________
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 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.