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
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Derby Name (can change at any time)
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Junior Skater's Date of Birth
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DD
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Junior Skater Cell Phone
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Junior Skater Email Address
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Parent/Legal Guardian Full Name
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Parent/Legal Guardian Cell Phone
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Parent/Legal Guardian Email Address
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Preferred Method of Contact
Mailing Address
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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.
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