Step 1: Fill in basic information about the skater/child.
First Name*
Last Name*
Birth date
What is your level of roller derby experience?*
How did you hear about St. Louis Junior Derby?*
SKATER CODE OF CONDUCT: By signing below I hereby agree that: 1. I will lead by example and demonstrate good sportsmanship with fellow skater, coaches, officials, parents, and other attendees at every game and practice. 2. I will make a concerted effort to attend every practice and bout. I will notify my coach or St. Louis Junior Derby Representative if I will be absent. I will be on time to practices and games. 3. I will listen and learn from my coaches and others. 4. I will treat my coaches, other members, officials, and fans with respect regardless of race, sex, creed, sexual orientation, gender identity, or abilities, and I will expect to be treated accordingly. 5. I deserve to have fun during my sports experience and will tell parents or coaches if it stops being fun! 6. I deserve to play in an environment that is safe and free of drugs, alcohol, and tobacco. I will not use drugs, alcohol, or tobacco. 7. I recognize the importance of school and will not allow my derby commitment to interfere with my academic success. 8. I will learn the rules of the game of Flat Track Derby according to the most current Junior Roller Derby Association (JRDA) standards. 9. I will not engage in any behavior which would endanger the health, safety, or wellbeing of coaches, parents, participants, officials, or any other attendees. 10. I will not engage in the use of profanity, verbal or physical threats, or any abuse aimed at coaches, parents, participants, officials, or any other attendees. 11. I will wear the appropriate practice or team uniform to all practices and bouts. My attire will be appropriate at all times as deemed by coaches and representatives. If I fail to abide by the aforementioned rules and guidelines, I will be subject to disciplinary action that could include but is not limited to the following: 1. Verbal warning by a St. Louis Junior Derby representative or committee member 2. Written warning 3. Player practice/game suspension 4. Player season suspension.
Parent/Guardian Info
Skater is in the custody of :*
Guardian #1*
Guardian #1 Phone:*
Guardian #2
Guardian #2 Phone:
If you are unable to be reached in an emergency, please list the name, phone number, and relationship of 2 adults who may take responsibility for your child: *
My Child is old enough and can leave/drive herself/himself.*
The parent or guardians listed above and the emergency contacts are the only individuals permitted to pick up your child. We may ask for photo ID to confirm. No other persons may pick up your child without prior WRITTEN consent. It is the responsibility of the parent/guardians to keep this information current. Please confirm your acknowledgement of this statement. *
I verify all information is correct and this is considered my electronic signature.*
PARENT/GUARDIAN CODE OF CONDUCT: By signing below I agree that: 1. I will not force my child to participate in the St. Louis Junior Derby. 2. I will promote the emotional and physical well-being of the skaters ahead of any personal desire I may have for my child to win. 3. I will inform the coach(s) of any physical disability, injury, or illness that may affect the safety of my child or other junior derby participants. 4. I (and my guests) will not engage in any kind of unsportsmanlike conduct with any official, coach, skater, or parent such as booing and taunting, refusing to shake hands, or using profane language or gestures. 5. I will not step onto the skate court during practice or scrimmage at any time unless invited by a coach. 6. I will encourage my child to play by the rules and to resolve conflicts without resorting to hostility or violence. 7. I will encourage my child to treat other participants, coaches, officials, and spectators with respect regardless of race, creed, color, sex, or ability. 8. I will respect the officials and their authority during games and will never question, discuss, or confront coaches at the practice facility and will take time to speak with coaches at an agreed upon time and place. 9. I will encourage a safe sports environment for my child that is free from drugs, tobacco, and alcohol. 10. I will refrain from coaching my child or other participants during games and practices, unless I am one of the official coaches. 11. I have read and understand all of the supplied information pertaining to the St. Louis Junior Derby. If I fail to abide by the aforementioned rules and guidelines, I will be subject to disciplinary action that could include but is not limited to the following: 1. Verbal warning by a St. Louis Junior Derby Representative or St. Louis Junior Derby committee member 2. Parental game suspension 3. Parental season dismissal.**
St. Louis Junior Derby is successful because of its volunteers! Would you be willing to help our us grow in any of these ways?
CONTACT LIST: St. Louis Junior Roller Derby will create a contact list to be shared with all skaters and parents to use. This will contain your child’s name and contact information along with your name and phone number. If you would like to opt-out of the information above being added to this list please check the opt-out box below.
VIDEO & PHOTO RELEASE AGREEMENT: For consideration which I acknowledge, I irrevocably grant to licensees, assigns, and successors the right to use my image and that of the minor in my charge 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 licensees, assigns, and successors from any claims that may arise regarding the use of my image including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright is permitted although not obligated to include my name as a credit in connection with the image. I have read and understood the photo release agreement. I (the undersigned) do hereby confirm the consent heretofore given you with respect to your photographing me or my child in connection with any video and any documentary. Additionally, I hereby grant to you, your successor, assigns, and licensees the perpetual right to use, as you may desire, all motion pictures and soundtrack 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.
Participant Medical Release
The Parent/Guardian must fill out a health history form in order to give St. Louis Junior Derby health care personnel all necessary background so that they can provide appropriate care. This form will be sent to the email entered previously. It must be filled out and brought to the first day of bootcamp in order for the minor to participate. It is required that all participants carry primary insurance for injuries. I hereby give my permission to the medical personnel selected by St. Louis Junior Derby 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 on the medical form). I will see that my child is kept away from practice in the event of illness or exposure to any communicable disease. I understand that every reasonable effort to contact a parent/guardian will be taken.*
As the parent or legal guardian of the minor listed previously, I hereby give authorization for participation in any and all St. Louis Junior Derby activities. I hereby grant permission to managing personnel and representatives to authorize and obtain medical care from any licensed physician, hospital or medical clinic, should the skater become ill or injured while participating in activities when neither parent nor legal guardian is present to grant authorization for immediate treatment. I assume all risks and hazards incidental to such participation, including transportation to and from activities, and for hereby waive, release, indemnify, and agree to hold harmless the St. Louis Junior Derby, and any junior league and its agents, assigns, representatives, officers and employees from any and all claims arising out of the skater’s participation in any and all activities. I HAVE READ AND UNDERSTAND ALL ENCLOSED INFORMATION. I VERIFY THAT I HAVE COMPLETED THIS FORM AND THAT THE INFORMATION PROVIDED IS TRUE AND CORRECT. I FURTHER AGREE TO ABIDE BY THE RULES/GUIDELINES SET FORTH BY THE JUNIOR ROLLER DERBY ASCCOCIATION AND MY REGIONAL JUNIOR DERBY LEAGUE, ST. LOUIS JUNIOR DERBY.
MEDICAL WAIVER: It is the responsibility of the undersigned to ensure that the above named person is medically fit to participate in strenuous on-rink or off rink activities. As stated below, participation in roller derby activities presents an inherent risk of injury to person or property. The undersigned certifies that the above named participant has no known conditions that prohibit or limit participation in any derby/skating activities held by or in association with the Junior Roller Derby Association (JRDA). Additionally, the undersigned must have Primary medical insurance in place for the participant to cover any expenses related to any potential injury that may arise from their participation in JRDA affiliated programs. Equipment and Skates: Participants must wear the following mandatory safety equipment during all roller derby on-rink activities and practices: knee, elbow and wrist pads, helmet, and mouth guard. Eyeglasses must have shatterproof lenses. The undersigned must take full responsibility that the above named participant (including self) is wearing the aforementioned safety equipment at all times and that it is properly worn. Only quad roller skates are permitted. All skates must be rink safe, meaning that their use must not gash, indent or blemish the skating surface or any other surface and that the skates will not cause injury to property or person(s). All liabilities thereof are undertaken by the undersigned. Participants should use the softest wheel composition available to achieve the best possible grip on the skating surface. Conduct: Spectators (patrons on the premises as a result of your involvement in any JRDA affiliated program) as well as participants must behave in a respectful manner to both person and property. Behavior which could potentially lead to intentional or unintentional bodily injury or injury to property will not be tolerated. Participation: The above named person is joining a JRDA affiliated program with the intention and goal of completing the prescribed training program, passing the safety skills assessment test and playing the sport of roller derby in accordance with the guidelines and codes of conduct set forth by the JRDA. It is the responsibility of the participant to inform their local program if they choose to withdraw from that program. Indemnification and Risk Acknowledgement: In consideration of being allowed to participate in any way in a JRDA athletic sports program, related events and activities, the undersigned acknowledges, appreciates and agrees that: 1. The risk of injuries from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury remains; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or other, and I assume full responsibility for my participation; and, 3. I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observer any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS JRDA and its local affiliation, the rinks, coaches, their officers, officials, agents, and/or employees, other participants, sponsoring agencies, sponsors and advertisers (“RELEASEES”) WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss, or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I HAVE READ THIS ASSUMPTION OF RISK AGREEMENT ACKNOWLEDGEMENT, AND I ACCPET RESPONSIBILITY; I FULLY UNDERSTAND ITS TERMS, AND I UNDERSTAND THAT I HAVE GIVEN UP MY SUBSTANTIAL RIGHTS BY SIGNING IT, AND I SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.*
CONCUSSION POLICY: Concussions are a serious injury and will occur in roller derby. The risk is extremely high for compounded head injury if someone sustains re-injury before they are sufficiently rested and recovered. Athletes and participants suspected of having a concussion should be removed from play immediately. • A concussion is a type of traumatic brain injury caused by a bump, blow, or jolt to the head that can change the way your brain normally works. Concussions can also occur from a blow to the body that causes the head to move rapidly back and forth. • Concussions should be suspected in the presence of any one or more of the following: symptoms (e.g., headache), or physical signs (e.g., unsteadiness), or impaired brain function (e.g., confusion), or abnormal behavior. • These are adapted policies based on The American Academy of Neurology Position Statement on Sports Concussion, which was adopted from the Consensus Statement on Concussion in Sport developed at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. • Any athlete who is suspected to have suffered a concussion must be removed from participation until the athlete is evaluated by a Physician with training in the evaluation and management of sports concussions • No athlete is allowed to participate in practices or games if they are experiencing symptoms from a concussion • Following a concussion, a neurologist or physician with proper training is to be consulted prior to clearing the athlete for return to participation. • Safety Personnel are required to be present at practices, games and events. • As a minimum standard, coaches, coaches, referees, captains or other support staff should be familiar with, have access to, and use the Sports Concussion Assessment Tools’ (SCAT2) Pocket Cards for field screening of suspected concussions. The minor and the guardian both understand this information.*
RETURN TO PLAY POLICY: Skaters are responsible for seeking medical attention for any injury sustained that affects the ability to safely skate and participate in roller derby. Skaters who have sustained serious injuries must be back practicing and fully participating in drills at least 4 weeks prior to competing in an official game. Serious injuries include but are not limited to fractures, partial or complete ligament tears, concussions, and any medical condition requiring surgery or overnight hospitalization. This requirement permits the injured skater to re-enter derby safely and it allows the team to get used to skating with the skater again. Coaches must obtain a formal doctor’s note from seriously injured skaters that are returning to play. The doctor’s note must specify whether the skater can return to skating with contact or skating without contact. If a coach feels the skater’s health is at risk then they may ask for more specific clearance from the skater’s medical professional. The doctor’s note will become part of the permanent skater file maintained by the league. If a skater, coach, or captain is unsure if an injury qualifies as “serious” or if the injured skater would like to appeal their situation then please consult with the Head of Training. In addition to following the advice of a medical professional please also consider the following factors before returning to skating: - Full, pain free range of motion of affected body part - Normal or average strength and power of affected body part - No excessive emotional concerns about re-injury - Functional stability: no limping or excessive compensation by other parts of the body for the affected body part - Relative freedom from pain Please be aware that re-injury is common when players return to sport before recovery is complete. This may be due to the athlete wanting to return to play, inadequate rehabilitation or external pressure from other players or coaches. Other injuries may occur due to athletes trying to protect their original injuries and subsequent altered behavior or biomechanics. The minor and the guardian have both read and understand this information.*
Monthly Payment
Bootcamp Session—$40