Individual Tryout Registration

First Name

Last Name

Last Name as it will appear on jerseys (In all CAPS)

Cell Phone #

City

Jersey # Choice 1

1-2 digits

Jersey # Choice 2

1-2 digits

Jersey # Choice 3

1-2 digits

Name of current roller hockey club (if any)

Waiver

Parent/Guardian Name

Agree

I agree to the above waiver.

Sign your name if you agree with the above waiver

Tryout Fee

Price$70.00

Would you like to donate to Senior Team USA?

Amount

Thank you!

CouponApply

Discount

Subtotal

Tax

Total USD