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