"Roller Kids" - Summer 2017
Membership Application
Email address *
Full name of the parent or legal guardian over 21 years *
Your answer
Relationship to the participant *
Your answer
Full name of the participant *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Street address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Contact phone *
Your answer
Contact email *
Your answer
In-line rollerblades skating experience *
Your answer
Will you need a FREE equipment rental ? *
YES / NO (please specify shoe size if YES)
Your answer
Health insurance policy *
number / provider
Your answer
Type of payment for the program *
Groupon / cash / check
Your answer
Submit
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