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Speedskating Contact Information
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Family name
*
Your answer
First name
*
Your answer
Street Address
*
Your answer
Street Address Line 2
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Phone
*
Your answer
E-mail
*
Your answer
Birth Date
MM
/
DD
/
YYYY
US Speedskating Member number
*
If not a member, type "none"
Your answer
Gender
*
Male
Female
Name of parent (if a minor)
Your answer
Parent phone
Your answer
Parent e-mail
Your answer
Emergency Contact Person
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Emergency Contact Phone
Your answer
Alternate Emergency Contact Person
Your answer
Alternate Emergency Contact Phone
Your answer
Emergency Information
Information to be shared with emergency personnel if person is unable to respond (allergies, medical conditions, etc)
Your answer
Information is confirmed and correct
*
Yes
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