CT Roller Derby (CT RollerGirls) Junior Derby Registration
Please complete one registration per child. This program is for girls ages 9-17.
Email address
Junior Skater's First Name
Your answer
Junior Skater's Last Name
Your answer
Has the junior skater participated in previous CTRD/CTRG junior derby programs?
Junior Skater's Age
as of January 2017
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Parent/Legal Guardian Full Name
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Parent/Legal Guardian Email Address
Your answer
Parent/Legal Guardian Phone
Your answer
Mailing Address
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Name of Primary Health Insurance Provider
Your answer
Health/Medical Insurance ID number
Your answer
Does junior skater have her own quad roller skates?
Rental skates will be available for skaters to borrow. Skaters are responsible for all other safety gear.
Junior skater’s Level of Skating Skill
Registration Fee
Registration fee for the 3 month (10 session) program is $150 per participant. Previous participants who recruit a friend (and their friend) save $25. Notify us at juniorderby@ctrollerderby.com to receive this discount. Please bring payment to the first session, cash or check (made out to CT RollerGirls).
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