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Junior Roller Derby Enrollment Form 2018
EastVic & South Sea Roller Derby are thrilled to be able to offer Junior Roller Derby classes and scrimmages again in 2018.
Please register below your interest as a new or renewing member.

For further information please contact us at evrdjuniors@gmail.com or read more about our program at
http://www.eastvicrollerderby.com/juniors

Skate Victoria Insurance form
https://docs.google.com/forms/d/e/1FAIpQLSdRsBo86HWTbleTDeftx3UMIF7Q49caEZlqtoV1J2oCr_-DcA/viewform

We will respond to all registrations via email prior to the term commencing to answer any questions and to acknowledge your enrolment.

EVRD /SSRD Junior Roller Derby Enrollment Form for 2018

Membership: *
First Name: *
Your answer
Second Name: *
Your answer
Derby Name (if you have one):
Your answer
Derby Number (if you have one):
Your answer
Gender: *
Your answer
Preferred Pronoun:
Date of Birth: *
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Address:
Your answer
Phone numbers (home, work, mobile): *
Your answer
Email Address: *
Your answer
Existing Medical Conditions: *
Your answer
Are you taking medications?
Allergies:
Your answer
Emergency Contact Name: *
Your answer
Relationship to Emergency Contact:
Your answer
Emergency Contact Phone Number: *
Your answer
Is the emergency contact person able to authorise medication administration?
Term Fees
MEDIA RELEASE: I consent to my child being photographed/videoed and the use of these photographs/videos by themselves, or in conjunction with other photographs/videos, for advertising, publicity, commercial or other business purposes for East Vic Roller Derby or South Sea Roller Derby. I understand that the term “photograph/videos” as used here includes still or electronic photographs/videos.I further consent to the reproduction and/or authorisation by East Vic Roller Derby or South Sea Roller Derby to reproduce and use these photographs/videos in all domestic and overseas markets. I also understand that others, with or without the consent of East Vic Roller Derby or South Sea Roller Derby may use and/or reproduce these photographs/videos.I hereby release East Vic Roller Derby, South Sea Roller Derby and any of their associated or affiliated companies, their directors, officers, agents, employees and customers, and appointed advertising agencies, their directors, officers, agents and employees from all claims of every kind on account of such use.All photographs/videos become property of East Vic Roller Derby and South Sea Roller Derby. Consent: *
Required
PERMISSION TO PARTICIPATE: I agree to the participation of my child/ward in East Vic Roller Derby in association with South Sea Roller Derby’s Junior Roller Derby program. I acknowledge that the Junior Derby Training Sessions will be under the direction and supervision of a Skate Victoria Accredited Coach. I acknowledge that I have completed the Skate Victoria Insurance form and will sign prior to my child attending training, the East Vic Roller Derby Code of Conduct. I agree that my child/ward will need to be equipped with all required safety gear before being allowed to participate in each session. Failure to wear all required safety gear will result in your child/ward being unable to participate in the session. *
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Parent/Guardian Name:
Your answer
Agree: *
Submit
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