Rolling Rebellion Membership Application

THANK YOU FOR YOUR INTEREST IN ROLLING REBELLION!

Based in Lewisville, Texas, the Rolling Rebellion Junior Roller Derby Team prides itself in its rigorous training program that takes absolute beginners with no prior skating experience and builds them into top-flight athletes.  In the past, four of our players were honored to earn a place on the Junior Roller Derby Olympic Team and our competetive travel team has been Junior Roller Derby Association (JRDA) nationally-ranked for the last four years.

Parent/Guardian and Participant Contact Information

Current Skating Ability - please choose the most appropriate answer *

Emergency Contact Information

General Policies

LOCATIONS AND PRACTICE TIMES

Practices are typically held on Mondays & Wednesdays from 6:30-8:30 pm and are open to all members.

Monday practices are currently held at Interskate Roller Rink located at 1408 S. Business Highway 121, Lewisville, Texas 75067.

Wednesday practices are currently held at Premier Event Center located at 1165 S. Stemmons Freeway, Lewisville, Texas 75067.

Practice times and locations are subject to change.

EQUIPMENT

Every skater on the track must have Quad (no inline) skates, elbow pads, wrist guards, kneepads, a helmet, and mouth guard.  Rolling Rebellion has limited "loaner" gear for first time attendees (except mouth guards) but you will be expected to purchase your own safety equipment within a reasonable timeframe.  Loaner gear is utilized at your own risk.  You may choose to purchase your gear from the Interskate shop located in front of the rink, or purchase gear in individual components from different vendors, local or online.  All protective gear must be worn during all skating activities. 

SKILL LEVELS

Roller Derby experience is not required.  We will teach you the skills necessary to play.  All skaters wishing to play competitively will be required to attain "bout assessed" status.  This is achieved by completing and passing the required JRDA Level I, Level II, and Level III skills/safety test and a written rules test. 

DUES

Dues are $60.00 per month and are due on or before the 1st of each month.  You can pay your dues in cash, check, or via PayPal.  Your child will NOT be allowed to skate until your monthly dues are paid in full.  There is also a $60.00 annual fee due on April 1st that covers skater insurance and JRDA dues.  If you have any questions about dues please contact finance@rollingrebellion.com.

AMENDMENTS AND REVISIONS

All amendments and/or revisions to the Rolling Rebellion's general policies or bylaws may be revisited and revised as deemed necessary by the league's Board of Directors.

Skater & Parent Positive Code of Conduct

POSITIVE INVOLVEMENT

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

I (the undersigned), DO HEREBY AFFIRM THAT I HAVE READ AND UNDERSTAND THE SKATER AND PARENT POSITIVE CODE OF CONDUCT.  

Parent/Legal Guardian Signature *
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Parental Authorization/Medical Release, Indemnity Agreements, Waivers, and Releases

PARENTAL AUTHORIZATION / MEDICAL RELEASE 

I, parent and/or legal guardian of the Participant, hereby give authorization for participation in any and all Junior Roller Derby Association League 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. 

WAIVER OF LIABILITY, RELEASE

ASSUMPTION OF RISK & INDEMNITY AGREEMENT

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 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.

PHOTO & VIDEO RELEASE

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.
 
I HAVE READ AND UNDERSTAND THE PARENTAL AUTHORIZATION / MEDICAL RELEASE, WAIVER OF LIABILITY RELEASE ASSUMPTION OF RISK & INDEMNITY AGREEMENT, VIDEO & PHOTO RELEASE, AND POSITIVE INVOLVEMENT CODE OF CONDUCT.  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 ASSOCIATION AND THE ROLLING REBELLION, LLC.
Parent/Legal Guardian Signature *
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Parent/Guardian Billing Information

Payment Options - please select one *
Payment Options - please select one *
Participation Frequency - please select one *
If you choose to receive a PayPal invoice, you can still opt to bring cash/check to practice. Cash & check payments will be accepted at practice up to 15 minutes prior to the start of practice (6-6:15pm) and again after practice. A PayPal account is NOT required to receive an online invoice and to pay via credit card. 
 
*If you are paying for multiple skaters, their dues will be combined on one PayPal invoice and only (1) $2 fee will be charged. Fee will only be charged when you are paying with a credit card and/or through PayPal. If you receive a PayPal invoice and decide to pay for that month with cash/check, the PayPal invoice and fee will be deleted after payment is received.

Returned Check policy is $25 fee for the first occurence; $35 fee for the second occurence, with no additional check payments accepted.

Please contact finance@rollingrebellion.com for questions about billing or fees.

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