Date:______________
Name:_____________________________________________________________
Address:___________________________________________________________
___________________________________________________________
Home Telephone: (____)________________E-mail :________________________
DOB: __________ *SS#: _______-_______-_______ *(Required
if selling raffle tickets)
Name of Spouse / Significant Other: ______________________ DOB:________
Unmarried children of applicant under the age of 21 and living at same address:
1._______________________________________________ DOB:____________
2._______________________________________________ DOB:____________
3._______________________________________________ DOB:____________
4._______________________________________________ DOB:____________
5._______________________________________________ DOB:____________
____$25.00/year Single
____$30.00/year Family
Please make checks payable to:
Bailey Hill Sporting & Recreation Club or BHSRC
Send application and payment to our treasurer:
Rhonda Elmadollar 696 Academy Street Ulysses, PA 16948
Heard about the Club from:
___Club Member ___Website
___Event Flyers ___Bulletin Board
___Other (Please specify)_________________________________
