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DACUSVILLE RECREATION

864-397-0480            www.dacusvillerec.org

Fields: 183 Shoals Creek Church Rd.  Easley, SC 29640

Gym: 2671 Earls Bridge Rd.  Easley, SC 29640


Circle Sport to Participate:

Baseball                      Basketball                   Soccer             Softball

T-Ball                           Volleyball       


Name: ____________________________________________________________________________________

Date of Birth: ________________                 Age: ____________________

School: __________________________________________________________        Grade: ________________

Allergies/Medical Condition:___________________________________________________________________

Primary Dr. / Dr Telephone: ___________________________________                 (______) ________________  


Parent/Guardian(s):

Mother’s Name: ____________________________________Father’s Name____________________________

Address: __________________________________________________________________________________

__________________________________________________________________________________________

Mother Cell Phone: (______) ________________   Father Cell Phone: (______) _________________________

Email: ____________________________________________________________________________________

**We can only honor same team requests for siblings**

Uniform size: ______________

Please circle if you are interested in volunteering:

Coach              Asst. Coach                  Team Parent               Volunteer

Dacusville Recreation may use photos of my child for promotional purposes: _______ YES ________ NO

***There is a $30 return check fee***

OFFICE USE ONLY:__________________________________________________________________________________

Amount Paid $ ____________                       Check # __________              Cash ___________

Date Received: __________               Received By: ___________                Receipt # ____________