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