Centerville Curling Club - CB Registration

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First Name

Last Name

Username

Password

Verify Password

Gender

Occupation

Age Range

Military ID

Address

Address 2

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:

Skill Level

# of Years Curled

Referred to the Club by

Full Time Student?

Member Since

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