NOTLD Registration

Please pay $20 registration fee by clicking PayPal Button after registering

Night of the Living Derby Registration
Must be registered by Sept 6th

* Indicates required field

Name *

First

Last

League Affiliation *

Email *

Phone Number *

Emergency Contact *

Derby Name and number *

Positions usually played *

Tag line *

WFTDA OR USARS # *

Choose One *

Female bouts Co-ed Bouts Both

how long have you played derby? *

0-1 years 1-2 years 2-3 years 3-4 years >4 years

What league affiliation?

T Shirt Size *

Small Medium Large 2XL 3XL

Submit

Email: beckleyareaderbydames@gmail.com

Main Practice Location:
110 High School Dr.
Mount Hope, WV 25880