Gotham Girls Roller Derby Online Registration

Registration

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Please complete the following registration form to create an account and register for Gotham Roller Derby's Basic Training , Junior Derby programs. *YOU WILL NOT BE CHARGED WHEN YOU ADD YOUR CREDIT CARD UNTIL YOU ENROLL* Junior Derby registrants: list at least ONE parent/caregiver and ALL others you wish to receive communications. Basic Training registrants: Only the primary and emergency contacts are required. You must list yourself in the Student section to view and enroll in classes.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Primary Contact Information

Skater or Family (if more than 1 skater attending) Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Name, Phone & Email*

Health Insurance Carrier*

Contact #1

First Name*

Last Name *

How Can We Contact You?

Home Phone

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

First Name

Last Name

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Skater Email (if different from above)*

T-Shirt Size

Disabilities*

Special Needs that will help us coach you?*

Allergies*

Medications*

Primary Doctor*

Any medical conditions we should be aware of?*

Most recent session attended?*

WFTDA insurance # (18+)

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Skater Email (if different from above)*

T-Shirt Size

Disabilities*

Special Needs that will help us coach you?*

Allergies*

Medications*

Primary Doctor*

Any medical conditions we should be aware of?*

Most recent session attended?*

WFTDA insurance # (18+)

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Skater Email (if different from above)*

T-Shirt Size

Disabilities*

Special Needs that will help us coach you?*

Allergies*

Medications*

Primary Doctor*

Any medical conditions we should be aware of?*

Most recent session attended?*

WFTDA insurance # (18+)

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Skater Email (if different from above)*

T-Shirt Size

Disabilities*

Special Needs that will help us coach you?*

Allergies*

Medications*

Primary Doctor*

Any medical conditions we should be aware of?*

Most recent session attended?*

WFTDA insurance # (18+)

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Birth Date*

Cell #

Additional Info

Skater Email (if different from above)*

T-Shirt Size

Disabilities*

Special Needs that will help us coach you?*

Allergies*

Medications*

Primary Doctor*

Any medical conditions we should be aware of?*

Most recent session attended?*

WFTDA insurance # (18+)

Please click on the Select Class button below, then choose the class.

Enroll in Classes

Select Class

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Please fill out ONE of the following Payment Methods

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

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Registration

Referral Information

Primary Contact Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies

(Show-Hide Details)