Membership Application
Please note: AJRD maintains a register of its members' data that is available to the Board of Directors.  The information you provide shall be held in confidentiality by the Board and disclosed only to coaches, team captains, and/or medical personnel in the event of an emergency.
Sign in to Google to save your progress. Learn more
Email *
Parent Name (goes with email) *
Skater Name *
Skater Pronouns *
Preferred Derby Name (n/a if unknown)
Preferred Derby Number (n/a if unknown)
Parent Phone Number *
That number is my...
Clear selection
Street Address *
City, Province, Postal Code *
Skater's Date of Birth *
MM
/
DD
/
YYYY
Skater Health Card Number *
Emergency Contact #1 Name & Number: *
This person is skater's... *
Emergency Contact #2 Name & Number:
This person is skater's...
Please list any medical conditions that we should be aware of (allergies, health risk, etc)
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Renegade Derby Dames. Report Abuse
Google Forms