ACR Dues Relief Form
Anchor City Rollers (ACR) requires all members to pay monthly dues (unless on an approved Leave of Absence, Parental Leave, or dues are relieved by a Board of Directors position). Monthly dues are payable to ACR’s VP Finance at

Anchor City Rollers considers itself an inclusive league and community, which states that all members should have access to participate in our league and play the sport we all love - roller derby. No one should be denied access to our sport because of financial reasons. Therefore, people who are unable to afford our monthly dues can apply for partial dues relief on the grounds of financial hardship. Applicants must demonstrate their need for financial assistance at the time of their application, and ongoing support will be reviewed monthly; however, in certain circumstances, dues relief may be provided for up to three months (90 days). To ensure consistency of these guidelines, members in need of continued support are expected to complete this application form again before the end of their approved dues relief.

The level of financial assistance offered is determined solely by ACR Executive Board of Directors members and can range from deferred payment terms to up to 50% dues relief. Application for dues relief will be considered by the Board of Directors Executive level, which may or may not include the President, Vice President, VP Finance, VP Admin, and Human Resources. Applications will first be reviewed by Human Resources. Non-identifying information and pertinent information may be discussed with the remaining Board of Directors Executives. A member of the Board of Directors Executives will contact applications if more information is required. All information will remain confidential. Additionally, a prior history of need is an important consideration; however, it is not a guarantee of future financial assistance through the dues relief program. After filling out your application, please contact a member of the Board of Directors Executives. Applications will not be approved until the applicant has spoken to an executive member of the Board of Directors.

Some examples of financial hardship include, but are not limited to:
-   Death of a family member, relative, or caregiver
-   Changes or loss of employment
-   Changes or loss of income
-   Damage to property (including houses and vehicles)
-   Loss of property (including eviction, victim of theft)
-   Injury or illness
-   Emergency event or natural disaster
-   Unexpected debt
-   Lack of funding for students

During the review and evaluation of the application, a Board of Directors Executive may contact you for more information. While we act through mutual respect, a request may be made to provide supporting documents (such as financial records or proof of need) that aid our decision. Additionally, in order to ensure our league remains operational, approved applicants may be required to participate in or volunteer at league events (including but not limited to fundraisers, promotional events, or working on a committee) in return of receiving dues relief. This also ensures the agreement and relationship is symbiotic between the league and recipient. An applicant will be informed of the decision as soon as it is made. Approved applicants will begin to receive dues relief the following month. Outstanding dues will not be reassessed unless proof of financial need can be backdated and requested by the applicant; in which case, we will attempt to work out a payment plan. Donations made to the Dues Relief Fund will not go towards outstanding dues.

If you have any questions, concerns, comments, or suggestions, please contact the Human Resources executive at 

If you are able to provide support to our dues relief program, please consider sending an e-transfer to ACR’s VP Finance at, and specify in the comment field “Donation to Dues Relief Fund”.
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Email address *
Why are you seeking financial assistance? (Please provide as much detail as possible to help us aid in making a decision). *
Do you currently have outstanding dues? *
Is there an existing arrangement in place for any outstanding dues?
Clear selection
Have you received Dues Relief before? If so, when and how many times. *
What assistance is being requested? *
How long do you needs dues relief for? *
Are you able to volunteer to help offset the cost of receiving dues relief? *
How do you see yourself volunteering with the league? If you already volunteer, please give a detailed description of what you have helped out with in the past and present.
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy