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: 

              Basketball Baseball Softball T-Ball

Volleyball       Cheer

  Childs Name: _______________________________________________________________________________

Date of Birth: ________________ Age: ____________________

School: __________________________________________________________     Grade: ________________

Allergies: __________________________________________________________________________________

Medical Conditions: _________________________________________________________________________

Parent/Guardian(s):

Mother’s Name: ____________________________Father’s Name:___________________________________

Address: __________________________________________________________________________________

__________________________________________________________________________________________

Home Phone: (______) _____________________     Cell Phone: (______) ____________________________

Email: ____________________________________________________________________________________

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

Uniform size: __________ Requested Number: ________

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

I Agree with the Release of Liability (see reverse) _________YES _________NO  

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

OFFICE USE ONLY:__________________________________________________________________________________

Amount Paid $ ____________ Check # __________ Cash ___________

Date Received: __________ Received By: ___________ Receipt # ____________

__________________________________________________________________________________________________

DACUSVILLE RECREATION

RELEASE OF LIABILITY

IN CONSIDERATION OF my child/ward, being allowed to participate in any way with Dacusville Recreation undersigned acknowledges, appreciates, and agrees that: The risk of injury to my child from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and, FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child’s participation; and, I am the parent/legal guardian of the Child/Children named below or I have obtained permission from the parent/legal guardian of the Child/Children named below to sign this agreement on their behalf. I give permission and accept full responsibility for the Child/Children to participate in the activities Dacusville Recreation. As a Condition to the Child’s/Children’s participation in the activities and by signing this form, I acknowledge and agree that: The operator(s) have advised me of the proper use and possible hazards of the activities; the Child/Children and I are solely responsible for deciding whether or not to participate or to rely upon any instructions, advice, or information regarding the activities;. it is not Dacusville Recreation’s purpose to teach safety before, during or after participation; I am solely responsible for the decision to allow the Child/Children to participate. I am of legal age and mental competence to knowingly give this acknowledgement and release which shall legally bind me and the Child/Children and our personal representatives, executors, heirs, and assigns. I HEREBY RELEASE AND WAIVE, ANY AND ALL CLAIMS , KNOWN AND UNKNOWN, THAT THE CHILD/CHILDREN OR I MAY NOW OR LATER HAVE AGAINST DACUSVILLE RECREATION, ITS MEMBER(S), OFFICER(S), INSTRUCTOR(S), OPERATOR(S) AGENTS, OR REPRESENTATIVES RELATED TO ANY ACT, OMISSION, STATEMENT, OR OCCURRENCE DURING OR RELATED TO THE USE OF THE THE FACILITY, FOR , LIABILITY FOR DIRECT, INDIRECT, VICARIOUS, PUNITIVE AND ANY OTHER DAMAGE WHETHER SUCH PARTY WAS INFORMED OR WAS AWARE OF THE POSSIBILITY OF SUCH LOSS OR DAMAGE.