Junior Derby Summer Camp Registration Form
Emerald City Junior Gems present Junior Derby Summer Camp for new or modified junior derby skaters.
Saturday August 20th 9:00am-3:30pm
Willamalane Center for Sports and Recreation
250 S. 32nd St. Springfield

Registration Deadline: August 15, 2016

Scholarship Deadline: August 1, 2016

Please make sure to complete all 4 pages of this form

Camper's legal name
Your answer
Camper's skate name, if you have one
Your answer
How did you hear about the Junior Gem's Camp?
Birth date
MM
/
DD
/
YYYY
Mailing Address
Your answer
Email Address
Email is our primary form of communication, including billing and information about the day. Please note if you do not have access to email regularly.
Your answer
Phone number
Your answer
What is your level of skating experience?
Are you a returning Gems skater?
If you have played junior derby, how long have you been actively skating? (Months/years)
Your answer
Do you have your own skates?
If you don't have your own skates, what size shoe do you wear? (Please specify adult or youth size)
Your answer
Do you have protective gear? (Check all that apply)
All skaters are required to bring a mouth guard already formed to fit.
Required
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