CT Roller Derby (CT RollerGirls) Junior Derby Registration
Please complete one registration per child. This program is for girls ages 9-17.
Email address
Junior Skater's Full Name
Your answer
Derby Name (can change at any time)
Your answer
Junior Skater's Date of Birth
Junior Skater Cell Phone
Your answer
Junior Skater Email Address
Your answer
Parent/Legal Guardian Full Name
Your answer
Parent/Legal Guardian Cell Phone
Your answer
Parent/Legal Guardian Email Address
Your answer
Preferred Method of Contact
Mailing Address
Your answer
Name of Primary Health Insurance Provider
Your answer
Health/Medical Insurance ID number
Your answer
Has the junior skater participated in previous CTRD/CTRG junior derby programs?
Does junior skater have her own quad roller skates?
Rental skates will be available for skaters to borrow. Skaters are responsible for all other safety gear.
Junior skater’s Level of Skating Skill
Registration Fee
Registration fee is $30 per calendar month per participant. We accept cash, check (made out to CT Roller Derby), Venmo, or PayPal (HR@ctrollerderby.com, please use "Send money to friends or family" option).
I am registering for the following months
Practices are held Sunday mornings from 10-11:30am at RollerMagic, 60 Harvester Rd, Waterbury CT.
Your answer
Please complete the captcha before submitting the form.
Never submit passwords through Google Forms.
This form was created inside of CT Roller Derby, Inc.. Report Abuse - Terms of Service - Additional Terms