Roller Derby High - Eltham Registration
Beginner Skating, Fitness & Fun for girls 12-17 years.

4 week program on Tuesdays 5pm-6pm from 12th March to 2nd April.

SKATERZ Skate Rink - 27 Susan Street, Eltham

For more information email office@skatevictoria.com.au

Given Name *
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Surname *
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Address *
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Phone number *
If applicant is under 18 years of age, please list the applicant's parents or guardians contact number.
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Email address *
If applicant is under 18 years of age, please list the applicant's parents or guardians contact email.
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Date of Birth *
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Roller Derby High membership required *
Do you have Ambulance Coverage? *
Your Skate Victoria membership does not include Ambulance coverage, please ensure you and your family have suitable coverage. Note that some states do not provide coverage interstate. You can refer to your state's link below for further information: VICTORIA - https://www.ambulance.vic.gov.au/membership/fees-terms/
Skate Victoria Code of Behaviour *
I will conduct myself and endeavour to ensure others in my company conduct themselves in a proper and reasonable manner and in accordance with Skate Victoria’s Codes of Behaviour. I agree to be bound by Skate Victoria’s constitution, rules and by-laws and the conditions of entry into the venue and to submit myself to the jurisdiction of Skate Victoria’s Tribunal, Member Protection Policy and any other disciplinary forum connected with Skate Victoria.
Required
Medical Information *
Do you have any medical condition which we should be aware of?
If you answered YES to the above question please fill in details here: *
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I have read the following information and understand it: *
For the purpose of the declaration in this form ‘SV’, its subsidiaries, its members (including Clubs) and their respective directors, officers, members, servants or agents RULES: I agree and acknowledge that the SV Constitution: (a) Constitutes a contract between me and SV. I will be bound by and comply with the SV Constitution, SV Rules and Regulations (Bylaws) and any SV policies as well as the rules, regulations and policies of the relevant club; (b) Is made in the pursuit of common objects, namely the mutual and collective benefits, of SV, the members of SV (including me) and skating activities; and (c) Is necessary and reasonable for promoting the objects of SV and particularly the advancement and protection of skating activities. PRIVACY STATEMENT: By applying to be a member I acknowledge and agree that: (a) the information I have provided in this form is necessary for the objects of SV; (b) the information I provide on this form will be used for the objects of SV and to provide services for me and for the purposes of registration, participation, team selection and insurance and it may be provided to SV, clubs and to its insurer; and (c) my information may also be shared with organisations associated with skating, including but not limited to the Australian Sports Commission and Australian Sports Anti Doping Agency. If I do not provide the information I may not be registered as a member. SV will comply with the Privacy Act with respect to the collection, storage and security of my personal details. RISK WARNING: Skating activities can be inherently dangerous and serious accidents can and do happen. I acknowledge that I am exposed to certain risks during skating activities including but not limited to falling, crashing into another person(s), being physically or mentally injured, impaired, maimed or killed and my property may be damaged lost or destroyed. I declare that I have voluntarily read and understand this warning and accept and assume the inherent risks in skating activities. EXCLUSION OF LIABILITY: I acknowledge that where I am a consumer of recreational services, as defined by any relevant law, certain terms and rights usually implied into a contract for the supply of goods or services may be excluded. I acknowledge that these implied terms and rights and any liability of SV (or any of its State Associations or clubs) flowing from them, are expressly excluded to the extent possible by law, by this membership declaration. To the extent of any liability arising, the liability of SV (or any clubs) will, at the discretion of the SV (or any of its clubs), be limited in the case of goods, to the replacement, repair or payment of the cost of replacing the goods and in the case of services, the resupply of the services or payment of the cost of having the services supplied again. RELEASE AND INDEMNITY: In consideration of SV accepting my application for membership I, to the extent permitted by law: 1. Release and will release SV (and any of its State Associations or clubs) from all actions, suits, proceedings, claims, demands, losses, damages, penalties, costs and expenses however arising, including but not limited to negligence, that I may have or may have had but for this release arising from or in connection with my membership and /or participation in any SV authorised or recognised activity; and 2. Indemnify and will keep indemnified SV (and any of its clubs) in respect of any actions, suits, proceedings, claims, demands, losses, damages, penalties, costs and expenses by any person arising as a result of or in connection with my membership and/or participation in any skating activities. 3. I acknowledge and consent to photographs and electronic images being taken of me while participating in any event recognised or authorised by SV. I acknowledge and agree that such photographs and electronic images are owned by SV and that SV may, in its sole discretion, use the photographs for promotional and other purposes without my further consent. 4. I also consent to SV using my name, image, likeness and performance in SV skating activities at any time to promote aims that SV, in its sole discretion, shall determine. 5. I acknowledge that SV cannot be responsible, and I agree not to attempt to hold SV liable, for any use of any image(s) that SV does not expressly authorise. PREGNANCY I acknowledge and agree that: (a) as a registered member of SV, I am a competitor/official with SV and am bound by the rules and regulations of SV; (b) the rules and regulations of SV are made in the interest of the sport of skating, the players and officials and SV, including: (i) Safety and protection of all players and officials; (ii) fair treatment of all players; and (iii) encouragement of safe and fair competition; (c) skating activities are activities in which contact occurs between players and between players and officials. Accordingly there is a risk to the health and wellbeing of myself and my unborn child by my participation in the sport whilst pregnant; (d) I will be bound by any rule or regulation of SV which is in operation from time to time in relation to pregnancy; (e) I: (i) indemnify and will keep indemnified SV (and any of its State Associations or clubs) from and against any and all actions, suits, proceedings, claims, demands, losses, damages, penalties, costs and expenses brought or commenced by any person at some time in the future in relation to any bodily injury, loss or damage which may have been sustained by me or my unborn child in or while being present at any skating activities or SV authorised or organised activity; and (ii) release SV (and any of its State Associations or clubs) from and against any and all actions, suits, proceedings, claims, demands, losses, damages, penalties, costs and expenses brought or commenced by me in relation to any bodily injury, loss or damage which may have been sustained or incurred by me as a result of my participation in any skating activities or my presence at any SV authorised or organised activity whilst I am pregnant. (f) Sports Medicine Australia considers contact sports and collision sports only in the first trimester of pregnancy; and (g) I have been advised that any insurance policy held by SV includes an exclusion clause in relation to any injury associated with pregnancy and childbirth SEVERABILITY The provisions (or any part of a provision) of this membership declaration shall be deemed to be severable and the invalidity or enforceability of any provision or any part of a provision of this membership declaration shall not affect the validity of this membership declaration.
Required
Fitness to Participate Declaration *
Fitness to Participate: I declare that I am medically and physically fit and able to participate in any Skate Victoria authorised or recognised activity of my choosing including competitions. By checking the AGREE box you agree that the information on this form is true and correct and will abide by the Skate Victoria Code of Conduct and have read all the information that is on this form.
Required
If under 18 my parent/guardian agrees and accepts all the above conditions on my behalf: *
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If under 18 please put Parent/guardian name *
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