"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
Please complete the captcha before submitting the form.
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