Roller Derby 101
Complete this form to register for PARD Derby 101 course.
Registration fee of $150 can be paid by cheque or cash (in person) or by e-transfer to
. Please make the answer to the security question the word "rollerderby."
Date of Birth
name of emergency contact person
emergency contact phone number
Have you played roller derby before?
If yes, where?
How did you hear about our Derby 101 course?
signed up at a community event
word of mouth
PARD home bouts
Do you want an appointment to try on gear with Rumbling Rage Skate shop on December 7th?
Yes! I want to make an appointment.
No thank you. I will handle finding gear on my own.
Send me a copy of my responses.
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