RRRD Registration Form

Riverina Rollers Registration Form

Participant's Information

Participant's Name

First NameLast Name

Preferred Name

Are you over 18 ?

Participant's Legal Guardian Name

First NameLast Name

Date of Birth

Date

Address

Street Address

Street Address Line 2

City

Postal / Zip Code

Mobile Number

Phone Number

E-mail

Skating skill level

	1	2	3	4	5

1 is Beginner, 5 is Advanced

Interested in Competing?

What position interests you?

Do you have Skates and protective gear such as helmet, kneepads, elbow pads, wrist guards.

What is your AU Shoe Size?

We will provide protective gear, they come in Small, Medium, large and Xlarge Do you know your size?

If you know your size please list

If you can please list below the reasons you decided to join Derby?

(Examples : Strengthening upper- body and core. Boosts endurance. Improving balance, competing, confidence etc. )

Important Notes · Bring a Water Bottle. Be prepared to fall.

You will need to purchase the relevant insurance from Skate Victoria and attach the recipt to this form.

SENIOR ONE MONTH TRIAL - If you wish to try for one month (only available once per year)
SENIOR DEVELOPMENT - Over 18 learning
SENIOR COMPETITIVE - Over 18 passed skills test (or 16+ Junior skater participating in adult roller derby activities - Dispensation, additional paperwork needed)
JUNIOR DEVELOPMENT - Under 18 learning
JUNIOR COMPETITIVE - Under 18 passed skills test
REFEREES - Over 18 refereeing roller derby including on skates and roller derby training does not cover participants for gameplay (scrimmages and bouts) as a participating skater, only as a Referee.
NON SKATING OFFICIAL - For participants 18 years and over who are off skates Officials.

Term fees are set January of each year and communicated to the team. Payments are due week 4 of each term (payment plans are available).

Emergency Contact & Health Insurance Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Do you have Ambulance Cover ?

Do you have Private Insurance?

Insurance Name

Medibank/Bupa/HCF etc

Name of Policy Holder

Does you have any allergies, breathing conditions , or medical conditions that would limit high level activtiy?

Please describe

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/SA (or any of its State Associations or clubs such as Riverina Rollers) 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/SA (or any of its States Associations or clubs such as Riverina Rollers) will, at the discretion of the SV/SA (or any of its State Associations or clubs such as Riverina Rollers), 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.

I have read and agree to the above conditions

I have purchased insurance from Skate Vic

Browse Files

Attach receipt of Insurance

Confirmation E-mail

Signature

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at riverinarollers@gmail.com .