Roller Club Registration

Name*
First Last
Birth Date*
MM
DD
YYYY
Email*
Phone
Address
Street Address Address Line 2 City State ZIP Code
Do you play ice hockey?*
- Yes
- No
If yes, what organization and what team did you play on this year? (Example: Waukesha Pee Wee C)
If no, would you rate yourself as a beginner or intermediate player?
Did you play club last season?*
- Yes
- No
Jersey Number Preference; Please choose 3 numbers*
List three numbers separated by commas.
2021 Scheduled Tournaments*
- Yes
April 9-11: NARCh Regional MKE, home rink
April 30-May 2: Cinco De Mayo, Des Moines, Iowa
May 14-16: Mid West Wars in Chicago
May 21-23: MKE Tournament at home rink
June 4-6: TORHS Regional Qualifier in Chicago
Nationals
TORHS Florida: June 25-July 4

By checking the box I confirm that I am able to commit to the National Tournament.
Comment
Include any comments or questions regarding the clinic, camp, or program.
Liability Waiver*
- Yes
I have read and agree to the liability waiver and terms and conditions.
Parent or Legal Guardian*