Skaters Name *

First Name

Last Name

DOB *

MM

DD

YYYY

Address

Your home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

WAIVER *

There is a standard of behaviour that is required. The skater must be in good physical & mental health to participate in the Gallardi & Gruhl Power Skating Classes.

I Agree