Southshire Juniors' Level 1, 2 & 3 Scrimmage
Reynolds-Gilchrest Memorial Building
11 Barton Ave
Hoosick Falls, New York 12090

Saturday, June 15, 2019 / 12PM - 4PM

Single Skater $10
Two Skaters $15
Three or more skaters in family $20

Email address *
Skater's Name *
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Derby Name *
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Skater's Number *
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Skater's Level (1, 2, or 3)
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Skater Insurance # (JRDA, WFTDA, etc)
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Parent / Guardian Name *
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Emergency Contact Info *
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League Association
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Any additional pertinent info we should know about the skater?
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