Crow City Derby
Waiver for Drop In Skater
Please read the waiver below and fill out additional information, this waiver is required to practice or skate with Crow City Derby.
Medical:
It is the responsibility of the undersigned (the Participant) to ensure that they are 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 roller derby, or roller skating activities, including off-rink activities (the “Roller Derby Activities”) held by or in association with Crow City Derby. Additionally,CCD recommends that the undersigned be covered by primary medical insurance as well as WFTDA insurance (optional) at all times to cover any expenses related to any potential injury that may arise from their participation in the Roller Derby Activities.
Skating Equipment:
The undersigned must take full responsibility that the above named Participant properly wears the following recommended safety equipment during all Roller Derby Activities: Mouth Guard, Knee Pads, Elbow Pads, Wrist Pads, and Helmet. Eyeglasses must have plastic shatterproof lenses. Only four-wheeled roller skates are permitted. Participants should use the softest wheel composition available to achieve the best possible grip on the skating surface. All roller skates must be rink-safe, meaning that their use must not gash, indent or blemish the skating surface or cause property damage. All equipment liabilities thereof are undertaken by the undersigned.
Conduct:
Participants signing this waiver must behave in a respectful manner to both person and property during Roller Derby Activities. Behavior, which could potentially lead to intentional or unintentional bodily injury or damage to property, will not be tolerated and questionable behaviors will be reviewed by CCD. If the behavior is found unacceptable, this may result in a participant’s expulsion from the premises and all Roller Derby Activities.
Indemnification and Risk Acknowledgement:
In consideration of being allowed to participate in any way in the Roller Derby Activities, the undersigned acknowledges and agrees that:
The risk of injuries from Roller Derby Activities 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 injury remains.
I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF CCD or its individual members (the “Releasees”) and I assume full responsibility for my participation.
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 CCD immediately.
I for myself and on the behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the Releasees with respect to any and all injury, disability, death, loss, or damage to my person or property.
Statement of Consent:
In the event of an emergency or non‐emergency situation requiring medical treatment, I hereby grant permission for any and all medical and/or dental attention to be administered to me, in the event of an accidental injury or illness, until such time as I am able to make responsible medical decisions for myself and/or one of my emergency contacts can be reached. This permission includes, but is not limited to,the administration of first aid, the use of ambulance, and the administration of anesthesia and/or surgery, under the recommendation of qualified medical personnel. Representatives, employees, agents, and volunteers of Crow City Derby are granted permission to seek such medical treatment, and I hereby agree to indemnify, defend and hold such persons harmless for any actions taken by such persons in reliance upon the Medical Release or any care rendered in reliance upon this Medical Release.
Photo Release Agreement:
For consideration which I acknowledge, I irrevocably grant to Crow City Derby (CCD), and CCD assigns, licensees, and successors the right to use my image and name 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 CCD and CCD assigns, licensees 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.
CCD is permitted, although not obligated, to include my name as a credit in connection with the image.
CCD is not obligated to utilize any of the rights granted in the Agreement.
I have read and understood the photo release agreement.
Drop In Skater Code of Conduct:
I will respect the privilege of use of the track, equipment, and Crow City Derby facilities.
I will treat everyone fairly regardless of gender, place of origin, color, sexual orientation, religion, political beliefs, economic status, team, or skating ability.
I will not engage in unsportsmanlike conduct with any coach, league official, skater or spectator.
I will not engage in any behavior that would endanger the health, safety, or well-being of any coach, league official, skater or spectator.
I will not engage in verbal or physical threats or abuse aimed at any coach, league official, skater or spectator.
I will play the game of Flat Track Derby per WFTDA requirements and the WFTDA Safety Policy.