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Welcome to the Quad City Rollers!
Please complete form below in its entirety. You will find below links to the Release of Liability Waiver and the Professional and Ethical Code of Conduct. Please read these first, fill out form and acknowledge below that you have read these.
https://docs.google.com/document/d/1J_dRG-TIRZ-glR0CwQrXwBe8IVpi_CZ8-quGB0xQudo/edit?usp=sharing
https://docs.google.com/document/d/1yEXh8OZndLyY6zc5GYvBr-8szBDW77pdkteWooXiASM/edit?usp=sharing
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Email
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First and Last Name:
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Pronouns:
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Date of birth:
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Home Address:
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Phone Number:
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Emergency contact:
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Relationship:
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Phone number of emergency contact:
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Address of emergency contact:
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Any medical conditions/allergies/surgeries that we should be aware about?
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In regards to the Release of Liability and Assumption of Risk Agreement:
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I have read this release of liability and assumption of risk agreement and fully understand and agree to its terms and conditions.
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In regards to the Professional and Ethical Code of Conduct:
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Acknowledgement of Understanding: I have read, agree, and will abide by the rules and regulation set forth by the QCR Professional and Ethical Code of Conduct.
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The use of this electronic medium shall have the same effect as an original signature. Please type name and today's date below.
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