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REHOBOTH BEACH PATROL
CITY OF REHOBOTH BEACH, DELAWARE
REGISTRATION FOR
U.S.L.A. MID-ATLANTIC REGIONAL CHAMPIONSHIPS

Rehoboth Beach Patrol, 1 Baltimore Ave & Boardwalk, Rehoboth Beach, DE 19971
Attn: Competition Director

* Indicates required information
All data received is for informational purposes only, and will be kept strictly confidential.

*Name (first, middle, last):

*Winter Address:
City: State: Zip:

*Age:

Sex: Male Female

*Birth date: (month/day/year)

*Email:

*Phone:(000) 000-0000

*Chapter:

*Agency:

Comments:

All registrants are required to sign a release form
upon receiving their competitor number.

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that your form has been sent- thank you

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