(Please print this form and mail, fax or drop-off):
Peachtree Road United Methodist Church – Sports, Recreation and Life Enrichment
3180 Peachtree Rd. Atlanta, GA 30305, or fax to (404) 266-0063.
Year: _______ Season: _____________ Age Group: ___________ Sport: ____________________________
Coach Name: ________________________________________________________ M ________ F _________
Have you coached with us before? Yes ___ No ___ (If yes please provide information that may need updating)
Phone H: ( )_________________ W: ( )__________________ C: ( )___________________
Facs #: ( )_______________ Email Address: _____________________________________________
Child’s Name: _________________________________ Other Coach: ___________________________
If you have not coached in our league in the last two years, please list employment information for the past two years:
Dates: From ___ to ____
I hereby authorize Peachtree Rd United Methodist Church to use the above information to check my background and employment history.
Name (please print): __________________________________, SSN ______________________
Signature: __________________________________________ , Date: ___________________