Membership Application
Please note: The information you provide shall be held in confidentiality by the league and disclosed only to coaches, team captains, and/or medical personnel in the event of an emergency.
Real Name *
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Preferred Derby Name
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Preferred Derby Number
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Phone Number *
Your answer
That number is my...
Email *
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Street Address *
Your answer
City, Province, Postal Code *
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Date of Birth *
MM
/
DD
/
YYYY
Health Card Number *
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Emergency Contact #1 Name & Number: *
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This person is my... *
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Emergency Contact #2 Name & Number:
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This person is my...
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Please list any medical conditions that we should be aware of (allergies, health risk, etc)
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