2018 BARRIE JUNIOR ROLLER DERBY NEW & RETURNING MEMBER WINTER REGISTRATION FORM
All Junior members of Barrie Junior Roller Derby are required to complete this registration form. Indicate any changes. This is our wait list form, if you are interested in being informed when a spot opens up please fill out this form.
I am *
Required
Child's Name *
First and Last
Your answer
CRDi Insurance number (Returning members only)
Your answer
Birthday Date *
DD/MM/YYY
Your answer
Address *
Your answer
City *
Your answer
Postal Code *
Your answer
Have you ever Roller Skated or Ice skated Before
Check all that apply
Allergies: *
If yes to the previous question please explain *
Your answer
Epi-Pen required
Previous Head injury/s: *
if there is none just fill in N/A
Your answer
Previous athletic injury/s: *
if there is none just fill in N/A
Your answer
Diabetes/Hypoglycemic: *
Epileptic: *
Do you wear glasses/contacts lenses? *
Other diagnosed medical conditions *
if there is none just fill in N/A
Your answer
Parent's / Legal Gaurdian *
First and Last
Your answer
Three Individuals who are permitted to drop off and pick up your child *
Your answer
Main Telephone number *
Your answer
Mobile Number *
Your answer
E-mail address *
Your answer
Which e-mail and phone number you would like listed in the directory *
Required
Membership Type *
Which program are you registering your child for. For LEVEL descriptions see our website http://www.rebelrollers.ca/jr-derby-levels.html
Permission to use photographic images: *
Photographs of Barrie Junior Roller Derby (BJRD) members may be used in various (BJRD) communications incl. Facebook, Instagram, Twitter and South Simcoe Rebel Rollers website. Group photographs taken at BJRD events may be used without identifying individual members. For individual photographs, please indicate your permission for use:
My Child and I have read and agree to the Parent and Skater Code of Conduct policy as well as the Anti-Bullying Policy *
Please click the link to read and print out your own copy of these three documents. Sign and bring a copy of all three forms with you on the first day of Juniors. https://goo.gl/71z9ET
Required
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