Skater Registration

North Texas Fallout

Skater Registration
Skater Legal Name*

First NameLast Name
Skater Birthdate *

MonthDayYear
Date
Skater Preferred Pronouns
blanks
Primary Parent/Guardian Name*

First NameLast Name
Primary Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Parent/Guardian Email*
example@example.com
Primary Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Parent/Guardian Name

First NameLast Name
Additional Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Additional Parent/Guardian Email
example@example.com
Additional Parent/Guardian Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Skater
relationship to Skater
Skater Derby Name
Derby name

Skater Number
Number

Please read the Parent Information
I have read the Parent information
Please read the JRDA Code of Conduct
I have read and agree to the JRDA Code of Conduct
Please read the Skater Code of Conduct
Skater has read and agrees to the Skater Code of Conduct
Please read the Parent Code of Conduct
Primary Parent/GuardianAdditional Parent/Guardian

   RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT

I,   First Name*   Last Name*   (together with my parent or guardian, if am under the age of eighteen or under a legal disability) represent, covenant, and agree, on behalf of myself and my heirs, assigns, and any other person claiming by, under, or through me, as follows:

I acknowledge that roller skating and skating the sport of junior roller derby are inherently dangerous activities, but still desire to participate in these activities at my own risk. If a parent or guardian of a minor, the undersigned agrees to allow the minor named to participate in these activities at his or her own risk.

I am further aware that the usual risks, hazards and dangers (hereinafter “risks”) of personal injury, death, disability, property damage and other loss, necessarily increase when wearing roller skates and playing junior roller derby. These risks include but are not limited to: falling, jumping, landing, skaters getting in front of you, skaters leaning on your, tripping over other fallen skaters, performing tricks, “show boating,” colliding with others such as staff, media personnel and spectators. These risks may vary from time to time and day to day based on the skater’s own fatigue (tired), equipment, type of event, and other factors, for valuable consideration, including permission to skate with the junior derby in any way, including but not limited to being permitted to compete, officiate, observe, or participate in any other way.

I hereby release, discharge, and covenant not to sue the North Texas Fallout, the Junior Roller Derby Association, the skate venues, their respective administrators, directors, agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owners and lessors of premises on which the Activity takes place, (each considered one of the "Releasees" herein) from all liability, claims, demands, losses, or damages on my account caused or alleged to be caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue operations; and I further agree that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, I, or anyone on my behalf, makes a claim against any of the Releasees, I will indemnify, save, and hold harmless each of the Releasees from any loss, liability, damage, or cost which any may incur as the result of such claim.;

I hereby ASSUME FULL RESPONSIBILITY for any risk of bodily injury, death or property damage arising out of or related to the use of the skate venue, its premises, or equipment, whether caused by an act of negligence of Releasees or otherwise.

I hereby agree to INDEMNIFY, SAVE AND HOLD HARMLESS the Releasees from any loss, liability, damage, or cost they may incur arising out of or related to the use of the skate venue, its premises, or equipment, whether caused by any act of negligence of the Releasees or otherwise.

I further agree that this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as possible.

I understand that participants are required to wear an adequate helmet, wrist guards, elbow pads, knee pads, and mouth guard while participating. Participants are required to follow all the rules of conduct and are not to take unreasonable risks while using the skate venue and playing junior roller derby, including causing any other skaters an unreasonable risk of harm.

I have read this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, understand that I have given up substantial rights by signing it, and have signed it freely and without any inducement or assurance of any nature, and intend it be a complete and unconditional release of all liability to the greatest extend allowed by law and agree that if any portion of this agreement is held to be invalid, the balance, notwithstanding, shall continue in full force and effect. Prior to signing this WAIVER AND RELEASE, I have had the opportunity to ask any questions about the WAIVER AND RELEASE, North Texas Fallout, and the skate venue.

EXECUTED  Date

Skater’s Derby Name
Derby name

Skater Legal Name

First Name   Last Name

Parent/Guardian is skater is under 18
First Name   Last Name

Skater or Parent/Guardian Signature
Signature

NORTH TEXAS FALLOUT
MEDIA RELEASE AGREEMENT

For consideration which I acknowledge, I irrevocably grant to North Texas Fallout, licensees, assigns and successors the right to use my image and name (if league member is over 18) or the image(s) and name(s) of my minor child(ren) or ward(s) named below (if league member is under 18) in all forms and media including composite or modified representations for all purposes, including advertising, trade or any commercial purpose throughout the world and in perpetuity.

I waive the right to inspect or approve versions of my image used for publication or the written copy that may be used in connection with the images.

I relinquish any right that I may have to examine or approve the completed product or products or the advertising copy or printed material that may be used in conjunction therewith or the use to which it may be applied.

I release North Texas Fallout, licensees, assigns and successors from any claims that may arise regarding the use of these images including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of
publicity or copyright.

North Texas Fallout is permitted, although not obligated, to include my name as a credit in connection with the image. I have read and understood the media release agreement.

I do hereby confirm the consent heretofore given North Texas Fallout with respect to photographing me or my child in connection with any North Texas Fallout event.

Additionally I hereby grant to North Texas Fallout, its officers, members, successors, assigns and licensees the perpetual right to use, as you may desire, all images, motion pictures and sound track recordings which you may make of me or my child, and the right to use my name
and/or child’s name or likeness in or in connection with the exhibition or any other use of such video or recording.

Skater
First Name   Last Name

Parent/Guardian of Skater under 18
First Name   Last Name

Signature
Signature

Date:   Date

Skater Derby Name:
Derby name

Skater Derby Number:
Type a label
Should be Empty:

North Texas Fallout

Health Registration