Toronto Junior Roller Derby - Registration - 2016/17
Name of Skater
First and Last
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Returning Skater
Required
Derby Name
please leave blank if name hasn't been chosen
Your answer
Derby Number
please leave blank if number hasn't been chosen
Your answer
Date of Birth
MM
/
DD
/
YYYY
Home Address
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Home Phone Number
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Email address of Skater
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Parent/Guardian Name
First and Last
Your answer
Address (if different from above)
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Parent's Email Address
Your answer
Emergency Contact Person
Your answer
Emergency Contact Phone Number
Your answer
Alternate Emergency Contact Name and Number
Your answer
Name of Other Parent or Guardian
Your answer
Address of Other (if different from above)
Your answer
Email Address of Other Parent/Guardian
Your answer
CRDI Insurance Number
(for returning skaters only)
Your answer
*Health Information
OHIP Number
Your answer
Name of Family Doctor
Your answer
Phone Number of Family Doctor
Your answer
Allergies and Treatment
Please list all...
Your answer
Medications
please list all...
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Permission Statements:
I hereby give my permission to the first aid administrator selected by the TJRD to secure emergency treatment for my child in the event that I cannot be contacted. I verify that my child is in good health and can participate in all activities (other than any listed), I will see that my child is kept away from practice in the event of illness or exposure to any communicable diseases. I understand that every reasonable effort to contact a parent/guardian will be taken*
*Electronic Signature and Date
by typing your name in the field below you are providing your electronic signature.
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