TJRD REGISTRATION - 2017/18
You will also need to review and sign the Consent Form package, the Concussion form and have valid CRDI insurance in order to complete your registration.
Name of Skater (real name)
First and Last
Your answer
Derby Name
Leave blank if name hasn't been chosen
Your answer
Derby Number
Leave blank if number hasn't been chosen
Your answer
Date of Birth (Day/Month/Year)
Your answer
CRDI Insurance Number
(for returning skaters only) CRDI numbers are valid for one calendar year.
Your answer
Home Address
Your answer
Home Phone Number
Your answer
Email address of Skater
Your answer
Returning Skater
Required
Parent/Guardian Name
First and Last
Your answer
Address (if different from above)
Your answer
Parent's Email Address
Your answer
Name of Other Parent or Guardian
Your answer
Email Address of Other Parent/Guardian
Your answer
Emergency Contact Person
Your answer
Emergency Contact Phone Number
Your answer
Health Card Number
OHIP Number
Your answer
Name of Family Doctor
Your answer
Phone Number of Family Doctor
Your answer
Medical Information
Please list below, any medical, social or emotional conditions which may be relevant to the coaching, care and treatment (emergency or otherwise) of your child/league member. All information will remain confidential unless it is necessary to share with the coaches to assist in the success of your child/league member's derby experience.
Your answer
Allergies and Treatment
Please list all...
Your answer
Medications
please list all...
Your answer
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
by typing your name in the field below you are providing your electronic signature.
Your answer
*Date Signed
MM
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DD
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YYYY
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