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