Sample Roller Derby Release Form printable pdf download

Release Form

League Name

Team logo above

Participant’s Name: ________________________________________________________

Date of Birth: _____________________ Home Tel #:___________________ Emergency #:____________________

Address: ____________________________________ City: _______________________ State: ______ Zip: _________

Email Address: _________________________________________

Parent’s Name: __________________________________________

Medical:

It is the responsibility of the undersigned to insure 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 USA Roller Sports (USARS). Additionally, the undersigned must have USARS membership in place for the

participant to cover any expenses related to any potential injury that may arise form their participation in USARS 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 and 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 us 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 USARS 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 USARS 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 USARS. 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 USARS athletic sports

program, related events and activities, the undersigned acknowledges, appreciates and agrees that:

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,

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,

I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe 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,

I, for myself and on behalf or my heirs, assigns, personal representatives and next of kin, HEREVY RELEASE AND HOLD HARMLESS

USARS 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 ACCEPT RESPONSIBILITY; I FULLY UNDRESTAND 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.

Parent’s Signature:________________________________________________________ Date Signed:___________________

Sample Roller Derby Release Form

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