Basic details

First name*

Last name*

Phone number*

Email address*

Address*

Additional information

Legal Name*

Preferred Name

Contact phone number*

Pronouns

Date of Birth*

Address* Max 255 characters

Emergency contact Name & Number*

Relationship to Emergency Contact*

Do you suffer from any medical conditions, recent or recurring injuries or taking any medications that BCR should be made aware of? (This may include, but is not limited to; asthma, allergies, epilepsy, ongoing usage of analgesic (pain-relief) medication*

yes

no

Please detail the nature of any medical conditions, or the usage of medications that BCR may need to be aware of? Max 255 characters

MEDIA RELEASE: Do you give permission for BCR to record & photograph the enrolling skater at events and training for social media & promotion?*

yes

no

How did you hear about Learn to Skate with Brisbane City Rollers?

Which intake session/s you plan to attend (all sessions are on skates so attending as many as you can is best for your development)*

20th July

23rd July

27th July

30th July

Do you require equipment?*

yes

no

What skating experience do you have? (1-4) 1. I don't know how to skate 2. I can roll & stop 3. I can skate but it's been a while 4. I'm confident on skates*

1

2

3

4

I hereby declare that the information provided is true and correct, and that I am physically and mentally fit to participate in roller derby training and all associated activities.*

Yes

I am aware of the inherent risks associated with roller derby and agree to adhere to all of the Brisbane City Rollers policies, procedures and the Code of Conduct at all times.*

Yes

Typing your full name here will be treated as a digital signature and affirmation that the information provided above is a true and correct record of both the details of the enrolling skater*

date signed*

Primary email*

Secondary email

Please note

A Learn to Skate Intake registration fee of $42.45 applies for this event.

Event Waiver

Brisbane City Rollers (member of Skate QLD/ Skate Australia) offers 'come and try' insurance to cover you during your first 21 days while you try skating with us!

This 3-week trial insurance membership is your chance to jump in and give skating a go! It is absolutely no cost to the participant and you have the peace of mind of being covered while you participate in the first 3 weeks of our Learn to Skate program and find out if derby is right for you :-)

This insurance membership can be used as many times as you like, in three-weeks (21 consecutive days). At the end of this period you can upgrade to Development Level to continue skating with us.

We will show you how to register for your 3-week trial on your first day of intake.