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Junior Roller Derby: Come and try!

Sun 26 Jul 2026 12:00 - 14:30
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Eagles Sports Complex, 109 Weedon St W, Mansfield QLD 4122

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Basic details

First name*

Last name*

Phone number*

Email address*

Address*

Additional information

Child’s Legal Name*

Child’s Preferred Name

Parent/ Guardian Name*

Parent/ Guardian Contact number*

Additional Parent/ Guardian Name

Additional Parent/ Guardian Contact phone number*

Primary Email*

Secondary Email*

Child’s Pronouns

Child’s Date of Birth*

Primary Parent/ Guardian Pronouns

Secondary Parent/ Guardian Pronouns

Address* Max 255 characters

Are there any current family law orders or parenting plans in place that relate to the child's care, welfare, or development?

If YES, please provide adequate information so we may support you 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

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

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)*

26 July

Do you require equipment?*

yes

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*

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*

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.

I confirm that I have read the above Event Waiver in its entirety.*

I agree to the Event Waiver.*

I am over 18, or, if I am under 18, this registration has been filled out by and endorsed by my parent or guardian.*

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