Rolling Rebellion Junior Roller Derby Summer Camp 2019

Participant and Parent/Guardian Contact Information

Current Skating Ability- Please choose the most appropriate answer *

Emergency Contact Information

Is the Participant Covered by Medical Insurance? *

Skater & Parent Positive Code of Conduct

When kids are surveyed about the reasons why they play sports, the #1 response kids consistently report is to have fun. In addition to the fun kids experience while playing sports, additional benefits from sport participation include physical, cognitive, and emotional growth and development. Unfortunately all of these things do not happen automatically, but instead occur as a direct result of our positive efforts as a team. It is in this spirit that the following Positive Involvement Code of Conduct Contract has been written to remind skaters, parents, volunteers, and coaches of a few important guidelines designed to help the team maximize its experience.
Respect the game, including your child, his or her teammates, and opponents. This means ensuring your child attends and comes prepared for all practices and games, and treats both teammates and opponents with dignity and respect. Good Sportsmanship means playing fair and safe, controlling negative emotions, and keeping the spirit of competition a healthy endeavor.
Respect the officials. Remember, roller derby officials (referees, non-skating officials) are an important part of the sport and add to the overall skater experience. It is important that you distinguish between bad calls as human error and wrong calls as when an official doesn't know the rule. In either case, it is important that you respect all officials and develop tolerance skills for when bad calls are made.
Refrain from coarse and threatening language, as well as all forms of physical aggression. There is never a place in youth sports to use vulgarities, threaten, intimidate, or use physical aggression.
Watch for the safety of all players at all times, including physical and emotional dangers. Be sure to pay attention to injuries, including concussions, and report and respond to them in a timely manner. Additionally, pay attention to signs of youth sport burnout and be sure to respond to your child if he or she needs help.
Cheer whenever possible, and stay away from booing and other negative fan behavior. Youth sports provide a great opportunity for positive fan support, including cheering. Booing and other negative gestures and language from the sidelines are never appropriate, so be sure to stay focused on positively supporting your skater's team at all times.
When attending Rolling Rebellion events, I/we therefore agree:
I/We will be a positive role model for my child/teammates and encourage sportsmanship by showing respect and courtesy, and by demonstrating positive support for all players, coaches, officials, volunteers, parents, and spectators at every game, practice, or team-related event.
I/We will not engage in any kind of unsportsmanlike conduct with any player, coach, official, volunteer, parent, or spectator such as booing, taunting, or using profane language or gestures, etc.
I/We will not encourage any behaviors or practices that would endanger the health and wellbeing of the athletes.
I/We will demand that all participants treat other players, coaches, officials, volunteers, parents, or spectators with respect regardless of race, sex, or ability.
I/We will never ridicule or yell at any participant for making a mistake or losing a competition.
I/We will respect the officials and their authority during games; will never question, discuss, or confront coaches or referees at the sporting event; and will take time to speak with coaches to air grievances at an agreed upon time and place.
I/We will refrain from coaching my child or other participants during games and practices, unless I am one of the official coaches of the team.
I/We will inform the coach of any physical disability or ailment that may affect the safety of my child or the safety of others.
I/We agree that if I fail to abide by the aforementioned rules and guidelines, I/we will be subject to disciplinary action that could include, but is not limited to the following:
Verbal warning by official, head coach, and/or member of the League Organization
Written Warning
Game suspension with written documentation of the incident
Season suspension
Parent/Legal Guardian Signature *

Parental Authorization/Medical Release, Indemnity Agreements, Waivers, Releases, and Policies

I, parent and/or legal guardian of the Participant, hereby give authorization for participation in any and all Junior Roller Derby Association League, Dallas Derby Devils, and Rolling Rebellion, LLC, activities. I hereby grant permission to managing personnel and league 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 league 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 league activities, and do hereby waive, release, indemnify and agree to hold harmless the JRDA 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 league activities.
It is the purpose of this agreement to exempt, waive and relieve releasees from liability for personal injury, property damage, and wrongful death, including if caused by negligence, including the negligence, if any, of releasees. “Releasees” include Dallas Derby Devils, and Rolling Rebellion, LLC, hereby referred to as HOST LEAGUE, its affiliate associations, local associations, member teams, event hosts, other participants, coaches, officials, sponsors, advertisers, and each of them, their officers, directors, agents and employees.
For and in consideration of the undersigned participant’s registration with HOST LEAGUE, its affiliates, local associations and member teams and being allowed to participate in events and member team activities, participant (and the parent(s) or legal guardian(s) of participant, if applicable) waive, release and relinquish any and all claims for liability and cause(s) of action, including for personal injury, property damage or wrongful death occurring to participant, arising out of participation in events, member team activities, the sport of roller derby, and/or activities incidental thereto, whenever or however they occur and for such period said activities may continue, and by this agreement any such claims, rights, and causes of action that participant (and participant’s parent(s) or legal guardian(s), if applicable) may have are hereby waived, released and relinquished, and participant (and parent(s)/guardian(s), if applicable) does(do) so on behalf of my/our and participant’s heirs, executors, administrators and assigns.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume all risks relating to roller derby and any member team activities, and understand that roller derby and member team activities involve risks to participant’s person including bodily injury, partial or total disability, paralysis and death, and damages which may arise therefrom and that
I/we have full knowledge of said risks. These risks and dangers may be caused by the negligence of the participant or the negligence of others, including the “releasees” identified below. These risks and dangers include, but are not limited to, those arising from participating with bigger, faster and stronger participants, and these risks and dangers will increase if participant participates in roller derby and member team activities in an age group above that which participant would normally participate in. I/We further acknowledge that there may be risks and dangers not known to us or not reasonably foreseeable at this time.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and agree that all of the risks and dangers described throughout this agreement, including those caused by the negligence of participant and/or others, are included within the waiver, release and relinquishment described in the preceding paragraph. I/We agree to abide by and be bound under the rules of HOST LEAGUE, including the By-Laws of the corporation and the arbitration clause provisions, as currently published. Copies are available to HOST LEAGUE members upon written request.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume the risks, if any, arising from the conditions and use of roller derby rinks/facilities and related premises and acknowledge and understand that included within the scope of this waiver and release is any cause of action (including any cause of action based on negligence) arising from the performance, or failure to perform, maintenance, inspection, supervision or control of said areas and for the failure to warn of dangerous conditions existing at said rinks, for negligent selection of certain releasees, or negligent supervision or instruction by releasees.
If the law in any controlling jurisdiction renders any part of this agreement unenforceable, the remainder of this agreement shall nevertheless remain enforceable to the full extent, if any, allowed by controlling law. This agreement affects your legal rights, and you may wish to consult an attorney concerning this agreement.
Participant (and participant’s parent(s)/guardian(s), if applicable) agree if any claim for participant’s personal injury or wrongful death is commenced against releasees, he/she shall defend, indemnify and save harmless releasees from any and all claims or causes of action by whomever or wherever made or presented for participant’s personal injuries, property damage or wrongful death.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge that they have been provided and have read the above paragraphs and have not relied upon any representations of releasees, that they are fully advised of the potential dangers of roller derby and understand these waivers and releases are necessary to allow amateur roller derby to exist in its present form. Significant exclusions may apply to HOST LEAGUE’s insurance policies, which could affect any coverage. For example, there is no liability coverage for claims of one player against another player.
The Junior Roller Derby Association (JRDA) and Rolling Rebellion, LLC (Rolling Rebellion), has adopted the following inclusion and gender definition policy, modeled on the Men's Roller Derby Association Non-Discrimination Policy ( The JRDA and Rolling Rebellion, pursuant to its mission of promoting junior roller derby, does not and will not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, citizenship, or military status, in any of its activities or operations. These activities include, but are not limited to, membership eligibility, disbursement of resources, and eligibility for office. JRDA and Rolling Rebellion are committed to providing an inclusive and welcoming environment for all skaters, officials, volunteers, and fans.
JRDA and Rolling Rebellion do not and will not differentiate between members who identify as male/female and those who identify as a non-binary gender (including but not limited to genderqueer, transmasculine, transfeminine, and agender). JRDA and Rolling Rebellion do not and will not set minimum standards of masculinity or femininity of its membership or interfere with the privacy of its members for the purposes of charter eligibility. The presence of a skater on a gender-specific charter is the only required evidence of that skater's gender identity for JRDA and Rolling Rebellion play.
In the event a JRDA or Rolling Rebellion member allegedly violates the Non-Discrimination Policy, notice must be given to JRDA and Rolling Rebellion with details of the complaint. JRDA and Rolling Rebellion will investigate and take appropriate actions.
For consideration which I acknowledge, I irrevocably grant to Rolling Rebellion, LLC, licensees, assigns and successors the right to use my image and (skater) name in all forms of 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. Rolling Rebellion, LLC, 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 Rolling Rebellion, LLC video or 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 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 connection with the exhibition or any other use of such video or recording.
I am over eighteen years of age.

Parent/Legal Guardian Signature *