TJRD REGISTRATION - 2019/20
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
Derby Name
Leave blank if name hasn't been chosen
Derby Number
Leave blank if number hasn't been chosen
Date of Birth (Day/Month/Year) *
CRDI Insurance Number
(for returning skaters only) CRDI numbers are valid for one calendar year.
Home Address *
Home Phone Number *
Email address of Skater
Returning Skater *
Required
Parent/Guardian Name *
First and Last
Address (if different from above)
Parent's Email Address *
Name of Other Parent or Guardian
Email Address of Other Parent/Guardian
Emergency Contact Person *
Emergency Contact Phone Number *
Health Card Number *
OHIP Number
Name of Family Doctor *
Phone Number of Family Doctor *
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.
Allergies and Treatment
Please list all...
Medications
please list all...
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.
*Date Signed *
MM
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DD
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