Personal Information
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Legal Name *
Derby Name *
Desired Jersey Number
Not guaranteed, if a current skater already has this number.
What kind of insurance do you have? *
Please check all that apply.
If you stated WFTDA or USARS in the above question, please enter your policy number.
Email address *
Phone Number *
Desired Transfer Date
Approximate is fine.
Will you reside in Columbus, or will you be commuting from another location?
Date of Birth *
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