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i heart derby mini bootcamp

i heart derby mini bootcamp

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Published by Jaims Cole
registration form
registration form

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Published by: Jaims Cole on Dec 03, 2012
Copyright:Attribution Non-commercial

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12/04/2012

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I Heart Derby Mini Bootcamp

February 16, 2013
Registration deadline: Feb 1, 2013
$25 Registration fee
Skater name: ____________________________________ Number: ____________ Sex:__________
Legal name: ______________________________________ D.O.B.: __________________________
Address: __________________________________________________________________________
Phone: ________________________________ Email: _____________________________________
Do you have insurance? YES/NO
Do you understand that by signing this document you hold River Valley Roller Girls, INC. harmless for any
injury that may occur at this event? YES/NO
Insurance provider: ______________________________ Policy number: _______________________
Skater insurance: USARS#: ______________________ WFTDA#: ___________________________
Emergency contact:
Name: _______________________________________ Number: _____________________________
Known medical conditions (Please note that this information will be kept strictly confidential unless
necessary in case of injury during event):
__________________________________________________________________________________
Please list any allergies (medication, food, latex, etc.)
__________________________________________________________________________________
League Affiliation: ___________________________________________________________________
Please Circle Scrimmages you wish to play in according to your skill level:
NOVICE INTERMEDIATE ADVANCED MENS COED
Signature of skater: __________________________________________________________________
Mail form and registration fee to:
River Valley Roller Girls
PO BOX 4716
Fort Smith, Arkansas 72914

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