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.
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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 *
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