Name *

First

Middle

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Date Of Birth? *

Derby Name *

If you don't have one just enter N/A

Derby Number *

If you don't have one just enter N/A

Medication Allergies *

Please list all allergies or medications allergies (if no allergies, type NONE)

Medical History *

Please list all medical history, surgeries, and conditions (If none apply, Type NONE)

Current Medications *

Please list all medications and supplements )If you do not take medications, type NONE)

WFTDA Insurance # *

WFTDA Insurance # (If you do not have WFTDA Insurance. please enter 000000

Medical Insurance Provider *

Do you have medical insurance? Please share your provider information (Including Member ID). If you do not have insurance, please type NONE.

Emergency Contact Name #1 *

Who do we call in an emergency?

Phone *

Emergency Contact Name #2

Phone

Do you have any professional skills the league could benefit from (Nurse, Graphic Designer, Accountant, Attorney, etc.)? Please list at least one skill. *

2023 Application for Membership

In this document (“Agreement”), Jacksonville Roller Derby, LLC. will be referred to as the Company.

Probationary Period

I acknowledge that as part of my membership, I must successfully complete a thirty (30) day probationary period during which my membership in the Company may be terminated, and that under such circumstances, I am not entitled to grieve the termination in accordance with the Policy and Procedures of the Company. Returning members may have their Probationary Period waived.

Membership Dues

I agree to pay monthly Membership Dues in one of the amounts listed in the Policies & Procedures, depending upon the Membership Status applied to me when my Probationary Period has concluded or right away if I am a returning member.

Membership Dues must be received by the date notated in the Policies & Procedures for each month through the life of this agreement. Dues are to be paid electronically via PayPal (dues@jacksonvillerollerderby.com) or via the Jacksonville Roller Derby website.

Members are responsible for payment processing fees, if applicable. PayPal payments can be sent via the "Friends and Family" option to avoid fees. Any fees not paid will be added to the next month's dues.
Cash or check payments will not be accepted at practice without prior approval by the Treasurer.
Payments received after the due date of each month will be considered late, and will be subject to a late fee.

I understand that if I fail to remain current in payment of Dues or other monies owed to the Company, I will be denied participation in all Company activities until past due amounts and all associated fees are brought current. This application constitutes an agreement by me to abide by the articles of organization and Policy and Procedures of this Company, and shall remain in effect until I resign my membership in writing, or the Company cancels my membership by procedures authorized in the Policy and Procedures, which are hereby incorporated by reference.

Attendance & Events Requirements

I acknowledge and understand that to be eligible for games or bouts, I must meet the minimum attendance point requirements. The league minimum attendance requirement for all Members is at least 50% for all practices, scrimmages, games, events, etc.

A member may only claim 25% of their overall attendance from non-JRD practices.
Members will receive 2 points per practice on skates, 2 points for coaching/training on skates, 2 points for officiating on skates, 1 point for an off skates practice, 1 point for coaching/training off skates, 1 point for officiating off skates at a practice, 1 or 0 points for less than full participation (Captain/Coach discretion), 0 points for no show.
Minimum attendance requirements may be lowered if practice is canceled by the league or by the practice venue.

I also understand that if I attend another league’s practice or an open scrimmage it is my responsibility to inform the league Secretary within 72 hours to receive attendance points.

I acknowledge and understand that I must also meet the Event requirements in order to be eligible for the bout roster. I understand that I must attend league events to be eligible for roster. If I have any questions about event points, I will contact the BOD.

Email Account Required

I acknowledge that I am required to establish / maintain an email account and to provide the address to the Company. This email address will be used for invitation to the Company’s Forum, as well as for any derby related communication or activities.

Rules and Limitations

I have, or will immediately read, the WFTDA official rules and skill requirements, available at www.wftda.com, and the Policies and Procedures of Jacksonville Roller Derby, LLC. It is my responsibility to obtain a copy of this document by requesting it via email from the Board of Directors.

I agree that all information discussed and disseminated within the Company is considered to be confidential and remains the property of the Company. Under no circumstances may anyone with membership in the Company disclose any inside information to anyone without Company membership, and specifically may not disclose information to a member of any other league, media, press, or social media/networking site without the express written consent of the Company’s Board of Directors or other authorized representative. This applies to but is not limited to, practice formats, training exercises, play books, forms or information, the business structure and management of any Jacksonville Roller Derby, LLC. sponsor, venue or facility, documented Policies and Procedures, or the bylaws and articles of organization. I may have my membership suspended or revoked and will be prevented from participation in any future league practices, games or events, and will not be eligible for readmission as a member of the Jacksonville Roller Derby, LLC. All members, including former members, will adhere to this clause.

Non-Competition

Any member choosing to cancel their membership, or whose membership has been canceled, may not use information or material from Jacksonville Roller Derby, LLC. for the purpose of forming a new league or aiding a competing league. Such activity will be considered a breach of this agreement and the Company reserves the right to take any appropriate action against the member or former member to protect its interests in retaining Company information as confidential. No person granted membership in the Jacksonville Roller Derby, LLC., may intentionally or knowingly attempt to recruit a skater from any other league. In the event a member is dismissed or chooses to leave the league, they may not recruit skaters, volunteers or staff from the Jacksonville Roller Derby, LLC., for any competing league, whether active or being newly formed. Such activity will also be considered a breach of this agreement.

Media Release

I agree that as a condition of membership in the Company, I will allow images or likeness of me, including photographs, video or other widely used medium, to be taken and subsequently used for promotions, training, publicity or any other use deemed appropriate by the Company. I understand I can request, in specific circumstances, that a specific image not be used, but that this request does not have to be granted by the Company.

Liability Release

I, my heirs, executors, agents, and/or assignees, voluntarily agree and promise not to make a claim against, sue, or attach the property of Jacksonville Roller Derby, LLC., or its venue, Skate Station Funworks and I forever release, waive, discharge and/or hold harmless the Released Parties of all demands, actions, and/or claims of liability arising out of their negligence, fault, recklessness, or any other act, omission, defect, or hazard that causes my illness, injury, death and/or theft or damage to my belongings. I assume all responsibility related to or incidental to my participation in membership activities.

WFTDA Confidentiality Agreement

Jacksonville Roller Derby is a member of the Women’s Flat Track Derby Association (WFTDA) and as part of that membership, all league members are required to sign a confidentiality agreement which states the league and/or its members will not share ANY information received by benefit of membership in the WFTDA with any league or any person not a member of the WFTDA. Failure to abide by the agreement could result in penalties, fines or other disciplinary action against Jacksonville Roller Derby and/or its members.

I agree to sign the WFTDA Confidentiality Agreement and any other WFTDA releases required on an annual basis. I agree to keep any and all information shared with me, by virtue of being a member of a WFTDA league, confidential and I will not share it with any league or any person who is not a member of the WFTDA. This agreement remains in effect even if my membership with Jacksonville Roller Derby is terminated.

2023 Member Intake Form