Columbus Curling Club - CB Registration

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First Name

Last Name

Username

Password

Gender

Birth date

Occupation

Age Range

Captcha

Address

Address 2

Company

City

Zip Code / Postal Code

Country

State / Province

Home Phone

Work Phone

Cell Phone

Work Extension

Emergency Contact Name

Emergency Contact Relation

Emergency Contact Phone #1:

Emergency Contact Phone #2:

# of Years Curled

Skill Level

Full Time Student?

Race or Ethnicity

Disability

Yes

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PO Box 14529
Columbus, OH
43214-0529