HCRD Juniors Registration
Skater Registration
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First Name *
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Last Name *
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Derby name (if you have one)
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Derby # (if you have one)
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Skater Intake Level *
City *
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Street Address *
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Postal Code *
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Birthdate *
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Email Address
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Phone Number
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If you already have Roller Derby insurance, type your carrier and insurance number below
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