HomeMy WebLinkAboutA6428 - COACHELLA VALLEY DERBY GIRLS - FACILITY USE AGR FOR DEMUTH COMMUNITY CENTER FACILITY USE AGREEMENT
(COACHELLA VALLEY DERBY GIRLS) }(
This Facility Use Agreement (" greement") is made and entered into this (lOkh day of
mwu` \,i , 201 , by and between the City of Palm Springs ("City") and
Coachella Valley Derby Girls("CVDG")concerning the use of the James O.Jesse Desert Highland
Unity Center("Facility").
RECITALS
WHEREAS,the City and CVDG are mutually interested in providing needed amenities and
community services to all residents of Palm Springs; and
WHEREAS, through this agreement, CVDG will be afforded the opportunity, on the same
basis as other lawful users,to provide services,including sports and recreation activities desired by
the community; and
WHEREAS,CVDG now desires to enter into this Agreement to obtain access and use of the
Facility, according to the terms and conditions stated herein.
NOW, THEREFORE, the City and CVDG do hereby mutually agree as follows:
AGREEMENT
1. TERM.
1.1. Term. This Agreement shall be in full force and effect for a period of one (1)year,
beginning February 1, 2015 and ending January 31, 2016. City and CVDG may renew this
Agreement for two (2) additional one (1) year terms, under the same terms and conditions stated
herein,except for any changes such as fees and charges for the use of certain facilities as specified in
Section 2.
1.2. Termination. City and CVDG may terminate this Agreement at any time, with or
without cause,upon sixty(60)days' written notice to CVDG. Nothing shall prohibit termination at
less than sixty (60) days' written notice upon any material breach of this Agreement.
2. FACILITY USE.
2.1. Facility Use. City grants CVDG the use of the Gymnasium,as identified in Exhibit
"B", and subject to the rules and regulations outlined in Exhibit "A". The Facility, and the areas to
be used by CVDG, are more specifically described in the attached Exhibit "B" and incorporated
herein by reference.
2.2. Schedulingof f Use. CVDG may use the Facility in accordance with Section 1.1 only
during the times specified in the Schedule and Fees,attached as Exhibit"C"and incorporated herein
by reference. The City may,in its sole discretion,alter the Schedule in order to maximize use of the
Facility for all users.
772567.1 1
2.3. Fees and Charges for Facility Use. CVDG agrees to pay City One Hundred Fifty
Dollars ($150.00) monthly, on or before the fifth of every month, for the use of the Facility for
regular Roller Derby practices. An additional late charge of$35 shall be due on all payments
received after the fifth of every month. In addition, all Roller Derby Participants shall obtain a
membership at the Facility in order to practice/play games. Special events such as games,
tournaments, clinics and workshops, occurring outside of regular facility hours will be charged as
outlined in Exhibit "C", Schedule and Fees.
2.4. Storage and Personal Property. Reserved.
2.5. Mailbox. Reserved.
2.6. Utilities. CVDG is responsible for establishing telephone lines,in separate accounts
from the City, and is responsible for payment of monthly accounts related to these services. All
other utilities shall be provided by the City. CVDG expressly waives any and all claims to the City
for compensation for any and all losses or damages sustained for any reason or any defect,deficiency
or impairment of any utility system, water supply system, drainage system, electrical apparatus or
wires serving the Facility with respect to the loss of the facility for CVDG functions.
2.7. Signs. No signs may be erected at the Facility, unless CVDG first obtains written
approval from the City. All signs posted by CVDG at the Facility shall conform to all applicable
Palm Springs Municipal Code and Palm Springs Zoning Code provisions.
3. SECURITY AND BACKGROUND CHECKS.
3.1. Background Checks. Any person having supervisory or disciplinary authority over
any minor is required to obtain a criminal background screening in accordance with the procedures
outlined in California Public Resources Code Section 5164. Provided that CVDG maintains
requirements for skaters to be at least 18 years of age, and there is no supervisory authority over
minors, CVDG shall be exempt from Security and Background Checks.
3.1.1. Supplemental Questions. Reserved.
3.1.2. Submission and Fingernrints. Reserved.
4. INSURANCE.
4.1. Minimum Insurance. CVDG shall procure and maintain,at its sole cost and expense,
in a form and content satisfactory to City, during the entire term of this Agreement, including any
extension thereof, the following policies of insurance:
4.LL Comprehensive General Liability Insurance. A policy of comprehensive
general liability insurance in an amount not less than One Million Dollars ($1,000,000.00) per
occurrence and in an amount not less than Two Million Dollars ($2,000,000.00) in aggregate.
Insurance companies shall have an AM Best's Guide Rating of A-, Class VII or better.
4.1.2. Workers' Compensation Insurance. To the extent required by the State of
California,CVDG shall procure and maintain workers' compensation insurance in the amount and to
the extent required by law.
772567.1 2
4.2. Proof of Insurance.Proof of the insurance required under Section 4 shall be provided
to City prior to the execution of this Agreement.
4.3. Primary Insurance. CVDG's insurance coverage shall be primary with respect to the
City and its respective elected officials,officers, employees, agents, and volunteers. Any insurance
or self-insurance maintained by City and its respective elected officials,officers, employees,agents,
and volunteers shall be in excess of CVDG's insurance and shall not contribute with it. For
Workers' Compensation and Employer's Liability Insurance only,the insurer shall waive all rights of
subrogation and contribution it may have against City, its elected officials, officers, employees,
agents, and volunteers.
4.4. Endorsements. CVDG shall obtain an Additional Insured Endorsement designating
the City, its officers, officials, employees, agents, and volunteers as additional insureds for liability
arising out of this Agreement. All endorsements shall reference that CVDG's insurance shall be
primary and non-contributory, as outlined in Section 4.3.
4.5. Deductible. Any deductibles or self-insured retentions must be declared to and
approved by the City prior to the commencement of this Agreement. At the option of the City,either
(1)the insurer shall reduce or eliminate such deductibles or self-insured retentions with respect to the
City, its elected officials, officers, employees, agents, and volunteers; or(2)CVDG shall procure a
bond guaranteeing payment of losses and related investigations, claim administration, and defense
expenses. Certificates of Insurance must include evidence of the amount of any deductible or self-
insured retention under the policy. CVDG guarantees payment of all deductibles and self-insured
retentions.
4.6. Amendment of Insurance Policy. CVDG shall not amend, or allow to be amended,
any insurance policy under this Agreement if such amendment is not consistent with the minimum
insurance requirements contained herein. Such amendment without the consent of the City shall be
considered a material breach of this Agreement and City may immediately terminate this Agreement
upon such occurrence.
4.7. No Cancellation of Insurance Policy. CVDG shall not cancel, or allow to be
cancelled, any insurance policy required under this Agreement. If said policies of insurance are
cancelled, CVDG shall,prior to the cancellation date, immediately obtain new insurance consistent
with the requirements of this Agreement and immediately submit evidence of such insurance to the
City.
4.8. Failure to Obtain Valid Insurance Dunne Use of the Facility. If CVDG is not
minimally insured,as required under Section 4,CVDG shall be considered in material breach of this
Agreement and City may immediately terminate this Agreement.
4.9. No Limitation. The provisions of this Section 4 shall not be construed as limiting in
any way the extent to which CVDG may be held responsible for the payment of damages to any
persons or property resulting from CVDG's activities or the activities of any person or persons for
which CVDG is otherwise responsible.
772567.1 3
5. INDEMNIFICATION AND DEFENSE.
5.1. Indemnification. CVDG agrees to indemnify the City, its officers, agents and
employees against, and shall hold and save each of them harmless from, any and all actions, suits,
claims, damages to persons or property, including injury or death to any person, losses, costs,
penalties, obligations, errors, omissions or liabilities (herein "Claims") that may be asserted or
claimed by any persons, firm or entity arising out of or related to this Agreement or CVDG activities
at the Facility, except to the extent that the Claim arises from the sole negligence or willful
misconduct of the City, its officers, agents or employees.
5.2. Defense. CVDG agrees to defend, with counsel acceptable to City, the City, its
officers, agents and employees against any Claims that may be asserted or claimed by any persons,
firm or entity arising out of or related to this Agreement or CVDG activities at the Facility,except to
the extent that the Claim arises from the sole negligence or willful misconduct of the City, its
officers, agents or employees.
5.3. Costs Associated with Indemnification and Defense. CVDG shall be responsible for
all costs incurred by the City that are associated with the indemnification or defense of City by
CVDG, including any costs associated with the use of City resources, including lost time by
employees, expended in furtherance of the indemnification or defense.
6. GENERAL PROVISIONS.
6.1. Notice. All notices,demands and requests which may be given or which are required
to be given by any party to this Agreement, and any exercise of a right of termination provided by
this Agreement, shall be in writing and shall be deemed effective either: (1) on the date personally
delivered to the address below, as evidenced by written receipt therefore, whether or not actually
received by the person to whom addressed; (2) on the third (3rd) business day after being sent, by
certified or registered mail, return receipt requested, addressed to the intended recipient at the
address specified below;(3)on the first(1 st)business day after being deposited into the custody of a
nationally recognized overnight delivery service(i.e.,FedEx Corporation,UPS,or DHL)addressed
to such party at the address specified below; or (4) on the business day sent via facsimile
transmission to the facsimile numbers below, as evidenced by a printed confirmation of the
successful electronic transmission of the message prior to 2:00 p.m. (Pacific Standard Time), or
otherwise delivery shall be considered to be on the following business day. For purposes of this
section, the addresses of the parties for all notices are as follows:
6.1.1. City.
City Manager
City of Palm Springs
3200 E. Tahquitz Canyon Way
Palm Springs, CA 92262
(760) 323-8299
772567.1 4
6.1.2. CVDG.
Coachella Valley Derby Girls
P. O. Box 2618
Palm Springs, CA 92263
760-835-9618
CVDG shall be responsible for notifying the City, in writing, of any changes in CVDG's address.
6.2. California Law. This Agreement shall be construed and interpreted both as to validity
and to performance of the parties in accordance with the laws of the State of California. Legal
actions concerning any dispute, claim or matter arising out of or in relation to this Agreement shall
be instituted in the Superior Court of the County of Riverside, State of California, or any other
appropriate court in such county, and CVDG covenants and agrees to submit to the personal
jurisdiction of such court in the event of such action.
6.3. Waiver. No delay or omission in the exercise of any right or remedy by a non-
defaulting party on any default shall impair such right or remedy or be construed as a waiver. A
party's consent to or approval of any act by the other party requiring the party's consent or approval
shall not be deemed to waive or render unnecessary the other party's consent to or approval of any
subsequent act. Any waiver by either party of any default must be in writing and shall not be a waiver
of any other default concerning the same or any other provision of this Agreement.
6.4. Rights and Remedies are Cumulative. Except with respect to rights and remedies
expressly declared to be exclusive in this Agreement, the rights and remedies of the parties are
cumulative and the exercise by either party of one or more of such rights or remedies shall not
preclude the exercise by it, at the same or different times, of any other rights or remedies for the
same default or any other default by the other party.
6.5. Legal Action. In addition to any other rights or remedies,either party may take legal
action,in law or inequity,to cure, correct or remedy any default,to recover damages for any default,
to compel specific performance of this Agreement, to obtain declaratory or injunctive relief, or to
obtain any other remedy consistent with the purposes of this Agreement.
6.6. Attornev's Fees. If either party to this Agreement is required to initiate or defend or
made a party to any action or proceeding in any way connected with this Agreement,the prevailing
party in such action or proceeding, in addition to any other relief that may be granted,whether legal
or equitable, shall be entitled to reasonable attorneys' fees.Attorneys' fees shall include attorneys'
fees on any appeal, and, in addition, a party entitled to attorneys' fees shall be entitled to all other
reasonable costs for investigating such action, taking depositions and discovery, and all other
necessary costs the court allows that are incurred in such litigation. All such fees shall be deemed to
have accrued on commencement of such action and shall be enforceable whether or not such action
is prosecuted to judgment.
6.7. Non-Liability of City Officers and Employ. No officer or employee of the City
shall be personally liable to CVDG,or any successor-in-interest,in the event of any default or breach
by the City or for any amount that may become due to CVDG or to its successor,or for breach of any
772567.1 5
obligation of the terms of this Agreement.
6.8. Conflict of Interest. No officer or employee of the City shall have any financial
interest,direct or indirect,in this Agreement nor shall any such officer or employee participate in any
decision relating to the Agreement that affects his financial interest or the financial interest of any
corporation,partnership or association in which he is directly or indirectly interested,in violation of
any state statute or regulation. CVDG warrants that it has not paid or given and shall not pay or give
any third party any money or other consideration for obtaining this Agreement.
6.9. Covenant Against Discrimination. CVDG covenants that,by and for itself,its heirs,
executors, assigns and all persons claiming under or through it,that, to the extent permitted by law,
there shall be no discrimination against or segregation of any person or group of persons on account
of race,color,creed,religion,gender,marital status,sexual preference,domestic partnership status,
national origin or ancestry in the performance of this Agreement.
6.10. Compliance with Governing Law. CVDG shall comply with all applicable laws,
codes, ordinances and regulations of the federal, state, and local government.
6.11. Interpretation. The terms of this Agreement shall be construed in accordance with the
meaning of the language used and shall not be construed for or against either party by reason of the
authorship of this Agreement or any other rule of construction that might otherwise apply.
6.12. Modification. This Agreement maybe amended at anytime by the mutual consent of
the parties by an instrument in writing.
6.13. Severability. hi the event that any one or more of the phrases, sentences, clauses,
paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by a
valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability
shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this
Agreement hereby declared as severable and shall be interpreted to carry out the intent of the parties
hereunder unless the invalid provision is so material that this invalidity deprives either party of the
basic benefit of their bargain or renders this Agreement meaningless.
6.14. Successors. The terms and conditions contained herein shall be binding on and inure
to the parties to this Agreement,their administrators,representatives,successors and assigns,except
as otherwise provided in this Agreement.
6.15. Assignment. CVDG may not assign or transfer its interest under this Agreement
_without City's prior written consent, which consent may be withheld, conditioned or delayed in
City's sole and absolute discretion. Any attempted assignment,sublet or transfer made in violation
of this provision shall be void.
6.16. Venue. Any action at law or in equity brought by either party to this Agreement
regarding the subject matter of this Agreement shall be filed in the Superior Court of the State of
California for the County of Riverside, Indio Branch,
6.17. Headings. The headings used in this Agreement are employed solely for convenience
of the parties and are not to be used as an aid in interpretation.
772567.1 6
6.18. Relationship. Nothing contained in this Lease shall be construed as creating the
relationship of principal and agent or of partnership or joint venture between City and CVDG.
6.19. Authority to Enter into Agreement.The persons executing this Agreement on behalf
of CVDG warrants that they are duly authorized to execute and deliver this Agreement on behalf of
said party,and by so executing this Agreement,such party is formally bound to the provisions of this
Agreement.
6.20. Counterparts and Facsimiles. This Agreement may be executed in any number of
counterparts,each of which shall be deemed an original and all of which shall constitute one and the
same instrument. Any facsimile of the original shall be treated as an original. The party submitting
any facsimile must submit a copy of the original to the other Party within a reasonable time after the
transmission of the facsimile.
6.21. Entire Agreement. This Agreement constitutes the entire Agreement between City
and CVDG. There are no oral agreements between the parties hereto affecting this Agreement. This
Agreement supersedes and cancels any and all previous negotiations, arrangements,agreements and
understandings, if any, between the parties, and none shall be used to interpret this Agreement.
[SIGNATURES TO FOLLOW]
7725671 7
IN WITNESS THEREOF, these parties have executed this Agreement on the day and year shown
below.
CITY OF PALM SPRING
Date:
David H. Ready, Cit anagerti.,Z
ATTESTED:
Date: 1�3�1fiI f�
ames Thompson, City Clerk
APP AS TO FORM:
Date:
Dougla C. Holland,City Attorney
APPROVED BY MY MANAGER
COACHELLA VALLEY DERBY GIRLS \aLML g� � L
Date: J
�nife matcham, President
Date: (� "
Irene Serrano, Treasurer
If CVDG is a corporation, a Corporate Resolution and/or Corporate Seal is required. If a
partnership, Statement of Partnership must be submitted to City.
772567.1 8
EXHIBIT "A"
(RULES AND REGULATIONS)
1. CVDG shall require users of the gymnasium to clean up after themselves and maintain the
gymnasium in a clean condition.
2. CVDG is responsible for maintaining the security of attendees and parked vehicles at the
Facility through its own efforts, within the scope of CVDG's use of the Facility or any
portion thereof.
3. All of CVDG's refuse and rubbish shall be removed on a regular basis at CVDG's sole cost
and expense. CVDG shall not place any rubbish or other matter outside any building within
the Facility, except in such containers as are authorized from time to time by the City.
4. No radio or television or other similar device audible outside the facility shall be installed
without obtaining in each instance the written consent of the City. No aerial shall be erected
on the roof,exterior walls or grounds of the Facility without first obtaining in each instance
the written consent of the City which consent shall not be unreasonably withheld or delayed.
Any aerial so installed without such written consent shall be subject to removal without
notice at any time.
5. No loudspeakers,televisions,phonographs,radios or other devices shall be used in a manner
so as to be heard or seen outside of the Facility without complying with the provisions of the
City's Noise Ordinance.
6. No sirens, outside paging or any type of signalization will be permitted, except approved
alarm systems.
7. CVDG will not allow animals, except seeing-eye dogs, in, about or upon the Facility.
772567.1
EXHIBIT "B"
(FACILITY)
James O Jessie Desert Highland Unity Center
Gymnasium and Outdoor areas
a j4
5
E" DERBY GIRLS PRACTICE
M, W, F for 2 HOURS r
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OUTDOOR GAME € +'
LOCATION (Special Events) .N" �1
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t*• � � °4 Y F 4 'it ��_ 1 i L tk o�n f
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a I .
RZ - Sa11tey Zone (Baseball field) §
Route to Safety Zone 6Z
® E%its to Safety Zone
772567.1
EXHIBIT "C"
(SCHEDULE AND FEES)
Use of Gymnasium for Roller Derby Practices
Schedule
Two-Hour time slot on Mondays and Fridays (6:00 pm to 8:00 pm) and Wednesdays (6:00 pm to
7:30 pm) based on current programming and staff availability
Note: The City of Palm Springs may require the use of the Gymnasium for special events from time
to time during CVDG scheduled use. In the event that the City requires such use, roller derby
practice may be temporarily moved to the outdoor basketball courts or to another City facility. The
City will give at least 72 hours advance notice to CVDG should this need occur.
All roller derby participants shall obtain membership at the facility and with that membership will
have access to the gymnasium and outdoor basketball courts for individual derby practice when not
in use for basketball or other programming.
CVDG shall not have access to the gymnasium during City observed holidays when the facility is
closed.
Fees
All roller derby participants shall obtain membership at the facility at a charge of$5.00 per year.
Additional Use of the Facility for Special Events including games, tournaments, clinics or
workshops will be charged the following fees:
$300 Security Deposit for events held in the gymnasium(fully refundable if no damages are
incurred)
$32/hour rental attendant fee (mandatory for all special events)
772567.1
Y 4AlAt d�
Department of Human Resources
rFo�N'" Holiday Schedule — 2015
CITY HOLIDAY SCHEDULE'
HOLIDAYS OBSERVED
PER PERSONNEL RULE 6.4.2 AND CALENDAR SCHEDULE2
ASONNEEDMDu' SCHEDULE CITY HALL.WILL BE CLOSED
ON THESE DATES
NEwYEAR' DAY THURSDAY —JANUARY 1,2015 THURSDAY-JANUARY 1,2015
I�
JANUARY 1
MARTIN LUTHER KING JR. DAY MONDAY—JANUARY 19, 2015 MONDAY—JANUARY 19, 2015
THIRD MONDAY IN JANUARY
PRESIDENTS DAY THIRD MONDAY IN FEBRUARY MONDAY—FEBRUARY 16,2015 MONDAY—FEBRUARY 16,2015
-
MEMORIAL DAY MONDAY—MAY 25,2015 MONDAY-'MAY25,2015
LAST MONDAY IN MAY
INDEPENDENCE DAY SATURDAY—JULY 4,2015 FRIDAY—JULY3,20153
JULY 4
LABOR DAY MONDAY-SEPTEMBER 7,2015 MONDAY—SEPTEMBER 7,2015
FIRST MONDAY IN SEPTEMBER
VETERANS DAY WEDNESDAY—NOVEMBER 11,2015 WEDNESDAY—NOVEMBER 11,2015
NOVEMBER 11
THANKSGIVING DAY THURSDAY-NOVEMBER 26,2015 THURSDAY-NOVEMBER 26,2015
FOURTH THURSDAY IN NOVEMBER
DAY AFTER THANKSGIVING 3
FOURTH FRIDAY INNOVEMBERFRIDAY-NOVEMBER27,2015 FRIDAY—NOVEMBER 27, 2015
CHRISTMAS EVE THURSDAY—DECEMBER 24, 2015 THURSDAY—DECEMBER 24,2015
DECEMBER 24
CHRISTMAS DAY FRIDAY—DECEMBER 25,2015 FRIDAY—DECEMBER 25,20153
DECEMBER 25
1 - Except for those classes of employees for whom a different holiday system (e.g. Holiday in Lieu) or list is
otherwise specked, the above dates will be recognized holidays for City employees (Personnel Rule 6.4.2 and
associated MOU's).
2 - The "Observed Schedule"applies to departments and/or work groups that follow a regular Monday-Thursday
work schedule. All other Departments and/or workgroups on other schedules use the "Calendar Schedule'unless
otherwise specified-
3-Holidays that fall on a Friday under the "Observed Schedule"will be credited to the employee's Floating Holiday
Bank.
Word/H/Forms/Benefits-Holiday Schedule 2015 June 2015
EXHIBIT"D"
(CVDG Application Packet Form)
•
,r
Welcome to the Coachella Valley Derby Girls (CVDG)!
The Coachella Valley Derby Girls is a non-profit organization that is operated by a 5 person
board of directors and several different committees,including Operations,Marketing, Fundraising,
Inter-League and Recruitment.As a member of this league,your membership will also include being
involved in a committee.
CVDG's goal is to create not only a team but a sisterhood where all women feel they are
equal, able to openly express themselves, promote the sport of Flat Track Roller Derby in the
Coachella Valley, and achieve their dream of becoming a roller derby athlete.
The dues collected and monies raised through fundraising as a team will go to reserving our
practice venue, purchasing supplies, website maintenance, merchandise, and other team expenses.
We are a competitive team and our practices are run accordingly. Our goal is to be the best
of the best and the best in the Coachella Valley! After our first team is up and running we plan to
start a Jr. Derby League.
0
772567.1
CVDG Requirements
All Participating Skaters must:
1. Be a female and at least 18 years of age
2. Provide a copy of valid photo ID/Drivers License and Insurance cards if covered
3. Read and sign the CVDG Liability and Model Release and acknowledgement
agreement
4. Attend at least 66% of all practices, events and community service functions.
5. Understand and accept the inherent risks of playing in the league as per the liability
waiver
Heath insurance is strongly encouraged and WFTDA insurance is required.
6. Read, understand and sign code of conduct.
All Street Team,NSO's and Refs must:
1. Be at least 18 years of age
2. Read, understand code of conduct
3. Attend at least 50%of all practices for refs and 1 practice weekly for NSO's(scrimmage day
is mandatory), events and community service functions
4. Understand the inherent risks of being involved in the league as per the liability waiver
Heath insurance is strongly encouraged And WFTDA insurance is required
(Refs)
5. Read and sign the Liability waiver and model release.
6. Complete WFTDA requirements as stated on their website www.wftda.com(refs and NSO's)
Coachella Valley Derby Girls Statement of Purpose
The Coachella Valley Derby Girls league(hereafter referred to as CVDG) exists to provide an
opportunity for women in the Coachella Valley and surrounding areas to participate in the
challenging and exciting sport of roller derby.
While the league is open to all qualified participants, certain standards are enforced to maintain
the integrity of the sport. This Handbook and Code of Conduct provides a guide to those
standards.
Who we are:
CVDG is the first all-female flat track roller derby league in the Coachella Valley.
CVDG was established in June of 2012 and continues to grow.
CVDG is a non- profit organization and is operated by a 5 person board of directors and several
different committees to ensure the league is run smoothly and efficiently.
Most importantly we are a competitive sport and will operate accordingly.
We currently practice 3 nights per week and participate in bouts and scrimmages.
Derby Names
One of the fun parts of derby is coming up with your derby name and number. Your derby name
can be whatever you want as long as it isn't already taken by a current teammate or too similar to
a current teammate. You derby number is whatever number you choose as long as it isn't already
772567-1
taken by a teammate. You can register your name and number on www.derbyrolicall.com
Uniforms
The purchase and maintenance of a team uniform is the responsibility of each skater. Protective
gear is also required.
Protective gear includes: Knee and elbow pads, wrist guards, helmet and mouth guard.
Note: Do not use any baubles, gems, decorations, or paint on your helmet or uniform that could
come off during skating and pose a hazard to other skaters. Anyone violating uniform standards
may not play in a bout. Check with your Captain or Operations Rep for team uniform
requirements and standards
Here are a few places that sponsor our team and provide a discount on product from their
businesses. This is a great way to pick up your gear at a discount.
Wicked Skatewear Bruised Boutique
10% off online for Entire League 10% off full price items in store and
online
DISCOUNT CODE= CoachellaValleyDG 15%off all Freshmeat packages (and free skate
http://wickedskatewear.com/ tool &mouthguard)
DISCOUNT CODE=COACHELLA 10
http://www.burisedboutique.com/onlinestore/
Rudechix Derby Warehouse
10% off online 10% off
COUPON CODE= DERBYASS COUPON CODE= CVDDG
www.rudechix.com www.derbMarehouse.com
Skizzo Kitty
15% in store
Practices
Practice time will be used for learning drills, building endurance, and increasing skating
knowledge.
Stay with the group and follow the instructions of the Coach. Show the Coach(s) respect. Notify
a Coach or Captain if you are unable to do particular drills due to an injury or other medical
issue.
We want to make the most of practice, and we want it to be challenging, fun and rewarding! If
you have suggestions for future practices please contact your Coach, Captain or other board
member.
Coach(s) will be available at practice to help you learn the game of roller derby, and will assist
you in equipment maintenance and skating fundamentals.
Always wear comfortable and appropriate clothes to practice. Be sure to bring all required
protective gear, skates and tennis shoes to practice, as well as a black and a white shirt for
772567.1
scrimmages. This gear is required or you will not skate. There will be off skate workouts so
please wear the proper attire and shoes.
Practice is set to start at a particular time. At the start time you should be geared up and ready to
go.
Remove jewelry such as necklaces and earrings, as they are a major hazard to other skaters if
they fall on the floor.
There is not eating or smoking during practice time whether you are skating or not.
There are no cell phones permitted during practice time whether skating or not.
At this time CVDG practices at DeMuth Community Center. We are on public property so all
league members need to show respect to other people in the public areas and please clean up after
yourself, remove all gear and trasb/recycling from the premises
At this time practices are open to the public as we are continually recruiting.
Bouts:
Our bouting season runs approximately February through November, and we usually have one
bout per month,beginning in February. However, promotional events occur year-round. Be
prepared to attend these events.
All league members are expected to attend bouts in uniform, if playing and team shirt if not
playing. All team members are expected to attend bouts for support even if you aren't skating.
Non skating team members will also be responsible for selling merch at the bouts.
ATTENDANCE POLICY:
All skaters are required to attend 66% of all eligible league practices and events to be considered
for a bout. Once committed to a roster you must make the week of practices before the bout or
you will be removed from the roster. No exceptions will be given except sickness, vacation or
work, all of which need to be cleared in advance with the Coach.
Events, fundraisers, and community service events are mandatory and also count toward
eligibility for a bout. You need to attend at least 66%unless otherwise cleared ahead of time. If
you are unable to make this attendance there is always "extra credit" for skating in your off time.
"Extra Credit" is 2 teammates skating for a minimum of 1 hour you will receive 'h an attendance
point. Participating in a scrimmage or a practice with another team will get you a full attendance
credit and watching a live bout or scrimmage will get you '/2 an attendance credit. This must be
reported via phone call, text message or message to Operations Committee Rep.
Injured players are expected to still attend practice and pay attention as this is still an excellent
learning opportunity,unless otherwise cleared. They can assist the ref team or other areas if
needed.
If you are going to have to miss a practice or event you must call the Coach, Captain or
Operations Rep. No Call,No Show will not be tolerated
772567.1
In case of a game absence you need to notify the Coach or Captain, so that you will not be
assigned a job at the bout.
In the case of extended absences from practice a board member. If a leave of absence is required
you can fill out the required form which will include a start and end date of the leave. Dues will
not be required, skating with CVDG will not be permitted during an LOA and communication is
a must. If there is no communication by the time of the end date, you will be removed from all
CVDG pages and will no longer be considered part of CVDG.
Refs must attend 50% of practices and NSO's are required to attend 1 weekly practice
(scrimmage night is mandatory) plus events, fundraisers and community service events.
Dues:
There are no dues the first month of skate as this is considered the trial period. They will be due
starting the second month of skating.
Dues are $30/month due on the 1"of the month, but no later than the 10`h of each month. Check
or money order preferred; cash will be accepted.
Dues are due whether or not you skate. If you choose to sit out for a month you still owe that
month's dues.
If your dues are not paid you won't skate.
If you dues for that month are not paid by the 10`h you will not skate until they are paid. If dues
are 2 months past due your name will be removed from the roster and you will no longer receive
team benefits until you are caught up. NO EXCEPTIONS. There will also be a late fee of$1 per
practice day until paid.
If special arrangements need to be made it will be up to the discretion of the team treasurer
and/or president and will be kept confidential between the individual skater and the treasurer
and/or president.
Leave of Absence: If you know you will be out of town or in school or any other foreseeable
event that will take you out of the practice schedule for any length of time a leave of absence
maybe scheduled with the Operations Representative. There will be a form with a start and end
date. Dues are not required during an LOA, and skating will not be permitted during this time.
Communication is a MUST. If there is no communication between the skater on leave and a
board member by the end date scheduled, then the skater will be removed from all team forums
and will be no longer considered part of CVDG.
Coaches, Ref's, NSO's and Street Team do not pay dues as they are doing a service for the team.
WFTDA Insurance
As a member CVDG all skaters are required to have WFTDA insurance(Women's Flat
Track Derby Association www.wfdta.com).The fee per skater is$75.00.It will need to be renewed
every calendar year.It is each member's responsibility to pay for their WFTDA insurance;it enables
skaters to be covered during practices and bouts. This fee is due at the end of the 1 month trial
period.
Drop In Skating:
Everyone is welcome to skate with CVDG, whether it is a skater from another team, or just
someone that has a pair of skates and wants to check it out or get a good work out. The charge
772567.E
for `drop in skating"will be$5, unless visiting from another league or anew skater in their trial
period. All drop in skaters are subject to the same code of conduct as we are and will have to
sign the necessary paperwork to join in.
Drop In Skating does not make you a team member; you will not be added to the roster and will
not receive team benefits.
Recruiting:
When recruiting or representing yourself as a CVDG League member you will be respectful to
those around you, including yourself. You will conduct yourself in a manner that will encourage
the general public to view or participate in CVDG events.
No member of CVDG shall EVER have the authority to deny or discourage anyone from joining
CVDG based on appearance, race, gender, sexual orientation, creed or abilities. Anyone meeting
the recruitment requirements is allowed to join CVDG and should be encouraged to do so.
Duties of Refs, NSO's and Street Team:
Refs: are just that referees for our roller derby league. Ref s are required to read,
understand and sign the code of conduct, pass the minimum skills test as put forward by
WFTDA, pass the required certification process as put forth by WFTDA, learn the rules and
signals of the game, purchase WFTDA insurance, take necessary ref classes and clinics and
attend 50% of all practices plus events, and community service events and scrimmage night is
mandatory.
NSO's: our Non Skating Officials (NSO) are required to read, understand and sign the
code of conduct, pass the required certification process as put forth by WFTDA, learn the rules of
the game and are required to attend one weekly practice,preferably scrimmage night plus events
and community service functions. As an NSO you are the time keepers, scorers, etc of the game.
Resignation:
Any team member wishing to resign from the team will need to file a letter of resignation with
the league Secretary or Team Operations Rep.
Minimum Skills:
Each skater and Ref is required to pass the minimum skills requirements as stated on the
WFTDA website. If you do not pass minimum skills you will not be eligible to bout.
Internet List Rules
The CVDG Facebook page, "A safe place to say it" and website are currently the main form of
communication for the league. It is recommended that you have a Facebook account for this
reason. Emails will be sent out regularly. If you are unable to access this site on a regular basis,
be sure to notify your Operations Rep to ensure you are receiving the information.
Please be respectful of you teammates on these forums and do not use these communication
forms as a way to express your grievances with each other.
Abuse of the CVDG sites can result in removal from the group and/or other disciplinary actions.
772567.1
Code of Conduct
The following code of conduct is designed to encourage and nurture the league's unique and
empowering culture.
The attitudes of league members have a significant impact on the league's success and reputation
in the community. In order to maintain a positive reputation, CVDG members are expected to
display professional conduct whenever representing or discussing CVDG in public. This means
always presenting a positive face for the organization as well as the sport of roller derby in
general. While this is by no means a gag order, the success of the league depends on a strong,
unified public image.
We cannot stress enough the importance of using the league's democratic structure to seek
change.
The league will continue to improve only if the women involved work in a cooperative and
respectful manner.
Of course, getting EVERYONE on the same page is at best, a utopian ideal. We are a team and
need to act accordingly. Not everyone will get along but we need to be respectful of each other
and our differences. If you can't work out a problem with the individual please bring it to a board
member and they will help you work it out. If further disciplinary action is required then the
board of directors will discuss and vote on the proper course of action.
Any aggressive threatening comments or behavior will not be tolerated. Violation may be
grounds for suspension or expulsion. What happens on the rink stays on the rink. More
importantly, what happens OFF the rink STAYS OFF the rink!
Alcohol/Drugs
All league members will refrain consuming alcoholic beverages or using drugs before and
during all CVDG bouts, scrimmages and practices, whether or not they are on skates. At the after
party and during non-skating league functions all league members are expected to maintain
control of their drinking. Failure to do so will result in disciplinary action.
Sexual Harassment Policy
CVDG is committed to providing an environment free of unlawful harassment. The league
maintains a strict policy prohibiting harassment of all forms. This policy applies to all CVDG
skaters and volunteers. Harassment in any form, including sexual, verbal, and physical
harassment is expressly forbidden. Sexual harassment includes, but is not limited to, making
unwanted sexual advances or requests for sexual favors, sexually motivated physical contact, or
other verbal or physical conduct or communication of a sexual nature where:
a) submitting to such conduct is made an explicit or implicit term or condition of participation in
league-related events;
b) submission to or rejection of such conduct by an individual is used as a basis for any decision
affecting that individual; or
c) such conduct has a purpose or effect of substantially interfering with an individual's
performance or creating an intimidating, hostile or offensive environment. Hostile environment
sexual harassment occurs when continued participation in the league is conditioned upon an
individual adapting to an environment where that individual is the target of repeated, unwelcome,
sexually derogatory remarks or physical contact of a sexual nature. The hostility of that
772567.1
environment is judged from the perspective of the victim.
Any volunteer or skater who believes that she or he has been harassed or has witnessed
harassment should report the incident to the Coach or Captain or any member of the Board of
Directors. Any Captain who receives a complaint must immediately report any incidents of
harassment to a member of the Board of Directors. The Board of Directors will investigate all
claims and take appropriate action, up to and including removal of individuals from the league.
Non-Compete Clause
While participating as a member of Coachella Valley Derby Girls (CVDG), you will not
participate with another roller derby league. You agree to not be a member of, train, assist or
game bout with another roller derby league unless given expressed authorization from the Board
of Directors.
Non-Disclosure
While participating as a member of CVDG you will not discuss any CVDG matters, including
but not limited to practice schedules of closed practices, strategies for practices or games,policy
and procedures, financials and all other CVDG business matters with anyone outside of CVDG.
CODE OF ETHICS:
COACHES:
I hereby pledge to provide positive support, care, and encouragement for all players (CVDG OR
OTHER)participating in roller derby by following this Coaches' Code of Ethics:
I will encourage good sportsmanship from players, fellow coaches, officials and visiting leagues
at every game and practice by demonstrating good sportsmanship.
I will place the emotional and physical well being of my players ahead of a personal desire to
win.
I will treat each player as an individual.
I will do my best to provide a safe playing situation for my players. I will check player's
equipment and rink.
I will never argue with or complain about a referee's calls or decision.
I will do my best to organize practices that are FUN and challenging for all CVDG players &
visitors.
I will teach CVDG players the Rules &Regulations or the game as stated in the WFTDA
guidelines.
I will remember that in recreational-sports everyone plays as much as is possible.
I will remember that I am a coach, and that the game is for the players. I will keep myself
informed of sound principles of coaching and am aware that there is always more to learn
PLAYERS:
I hereby pledge to provide positive support, care, and encouragement for everyone involved in
roller derby by following this CVDG Players' Code of Ethics:
I will encourage good sportsmanship from fellow players, coaches, officials, and visiting leagues
at every game and practice by demonstrating good sportsmanship.
I will remember that sports participation is an opportunity to learn and have FUN!
I will be on time for every practice and game that I can, and will notify my coach in advance if I
772567.1
cannot.
I will do my very best to listen and learn from CVDG Coaches as well as Guest Coaches.
I will do my best at every practice &game, working hard to improve my skills and to help my
team.
I will never argue with or complain about a referee's calls or decision.
I will control my temper and resist the temptation to retaliate if I feel I've been wronged.
I will treat my coaches, other players, officials and spectators with respect regardless of race,
gender, creed or abilities and I will expect to be treated accordingly.
I will play by the Rules & Regulations of the game as set forth in the WFTDA Guidelines.
CVDG is my league, regardless of my team assignment. I will treat all of my league members
with care and respect.
Terms and Conditions
The rules and agreements set forth by this handbook can be changed and amended at anytime and
you will be given notice prior to the change. By signing below you agree to any future changes
or amendments.
I have read, understand and agree to abide by the rules, code of conduct and code of ethics set
forth in this handbook.
Legal Name: Signature:
Date:
772567.1
Registration Form
*Please Print Legibly!*
Date:
Name DOB:
Cell: ( ) Mobile Carrier: Home:
Email
(required):
Mailing Address: Apt:
City State Zip
How did you bear about CVDG?
On a Scale of 1-5 (5 = Excellent) How well do you skate
1 2 3 4 5
What do you know about roller derby?
Why do you want to be a part of roller derby?
We need Sponsors, Equipment, Volunteers, Merchandise, Artwork, Money etc, Please list any
special skills or resources that you may be able to offer to Contribute to the league:
772567.1
Tell us about YOU! What are your hobbies? What do you do in your free time? Do you have any
pets? Etc...
Emergency Contacts & Medical Information Sheet
*Please Pant Legibly*
This form will be used in case of an emer ency:
Information will be provided to Medical treatment staff.All information remains
confidential.
Attach a copy of Your insurance card (front and Back) and you Photo ID
OR Email copies to Operations Director Jen Matcham at jenmatcham@gmail.com
INSURANCE CARRIER:
ID#: Group #:
Policy Holder: Policy Holder DOB:
Relationship:
Name: DOB:
Address: City: Zip:
Phone: Cell: Carrier:
Emergency Contact(Required):
Name: Relationship:
Cell Phone: ( ) Home Phone: ( )
Address: City: State:
Zip:
Secondary Emergency Contact:
Name: Relationship:
772567.1
Cell Phone: ( ) Home Phone: ( )
Address: City: State:
Zip:
Preferred Hospitals: (The following facilities are covered by my insurance)
1. 2.
Do you have Advanced Care Directives? Yes No
Medications Currently Taking(List any OTC or prescription medications and
vitamins/supplements):
Food/Drug Allergies (and short explanation if necessary):
Serious Medical Conditions (seizures, fainting, diabetes, etc...)
Family History of Medical Conditions (immediate family most importantly):
Do you smoke? No Yes - Quantity per
Consume Alcohol? No Yes Quantity per
Any Other hiformation we should provide doctors?
772567.1
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in anyway, at anytime, in Women's Flat
Track Roller Derby
("Activity"), I, for myself, my personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of this Activity, and that I am
qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and
warrant that if, at any time, I believe the conditions to be unsafe, I will immediately discontinue further
participation in this Activity.
2. FULLY UNDERSTAND that: (a)THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS
BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("Risks"); (b)these Risks
and dangers may be caused by my own actions or inactions, the actions or inactions of others
participating in the Activity, the conditions in which the Activity takes place, or THE NEGLIGENCE OF
THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS or SOCIAL AND ECONOMIC
LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES
I incur as a result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE,AND COVENANT NOT TO SUE the sanctioning organization(s),
their administrators, directors, agents, officers, members, volunteers, and employees, other participants,
officials, rescue personnel, sponsors, advertisers, owners and lessees of Premises on which the Activity is
conducted, (each of the forgoing shall be considered one of the RELEASEES herein) FROM ALL
LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED, OR ALLEGED
TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEES OR
OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS;AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY
AGREEMENT I, or anyone on my behalf, makes a claim against any of the RELEASEES, I WILL
INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses,
attorney fees, loss, liability, damage, or cost which may be incurred as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND
FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY
SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE,
AND
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE
GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD
TO BE
INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT,
PRINT NAME & LEAGUE NAME:
PARTICIPANT'S SIGNATURE:
ADDRESSS:
772567.1
(Street) (City)
(State) (Zip)
PHONE:
DATE:
PRIMARY HEALTH INSURANCE CARRIER:
WFTDA Adult W&R 1117111 DME 01807672
02011 Women's Flat Track Derby Association(WFTDA)
MODEL RELEASE AGREEMENT
For valuable consideration received, I hereby grant to Coachella Valley Derby Girls, or anyone
authorized by them, the absolute and irrevocable right and permission, in respect of the
photographs, video, or any other form of media, taken of me, or in which I may be included with
others, to copyright the same, in their own name or otherwise; to use, re-use, publish, and re-
publish, the same in whole or in part, individually or in matter, in any and all media now or
hereafter known, and for any purpose whatsoever; and to use my name in connection therewith if
they choose.
I hereby release and discharge the Coachella Valley Derby Girls or anyone authorized by them
from any and all claims and demands arising out of or in connection with the use of the
photographs/video/other media, including without limitation, any and all claims for libel or
invasion of privacy. This authorization and release shall also insure to the benefit of the heirs,
legal representatives, licensees, and assigns of Coachella Valley Derby Girls and those
authorized by them, as well as the person(s) for whom the photographs were taken.
I am of full age and have the right to contract in my own name. I have read the foregoing and
fully understand the contents thereof. This release shall be binding upon me and my heirs, legal
representatives, and assigns.
Legal Name: Signature:
Date:
772567.1
EXHIBIT"E"
(CVDG Waivers)
Attached are copies of the signed Release and Waiver of Liability, Assumption of Risk and
Indemnity from CVDG members.
7725671
RELEASE AND WAIVER OF LIABILITY9 ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"), I,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS,AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH ("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO ,SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees,;otiter participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is"conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS;:DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERA ONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RIS&-)i D INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I)WILL INMi NI#Y,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF,ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION Q,F, THIS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE,NOTWITHSTANDINJG, SHALLCONTIINUE hN�.�(.d FORCE AND EFFECT..
PRINT NAME&LEAGUE NAME:
PARTICIPANTS SIGNATURE:
ADDRESS:3 7 )` � 1 bE )(j t(( la (Ar 17Z�_
(� (street) } (State) (Zip)
PHONE: I��fl 7_Y — GJ 17I 12 DATE: 7 � 5
PRIMARY HEALTH INSURANCE CARRIER: M f/-/"4 (/
WFTDAAdu1tW&R 1117111 DME 01907672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"), I,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE ORIN;PART,BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS;;AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL. RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY''PORTION OF CIS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE, NOTWITHSTANDING,SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: l`/e"T),<---F�--ft k rIAS RFLsnsE
PARTICIPANTS SIGNATI�E:
ADDRESS: k
(Street) (City) 11 (State) (zip)
PHONE: . J 4-ao 291P DATE: 41
PRIMARY HEALTH INSURANCE CARRIER:U ►�P
WFMAMAW&R I1n111 DME41807673
RELEASE AND WAIVER OF LIABILITY9 ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date,in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1, for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity, and that I am qualified,in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SITE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is-oonducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,.DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR INPART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT 1 HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OFf THIS'AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE ANDEFFECT.
PRINT NAME&LEAGUE NAME: Amt, ofiAdsvERE o / " !r
PARTICIPANTS SIGNATURE: 7 /J /[ _ J• l r� / /
ADDRESS: 3030 J�lenlGt�- &W1k L(11 Vk / �h CAA
(Street) LW te) -(zip)
PHONE: C7 �� DATE: �7 /ZOO /�S
PRIMARY HEALTH INSURANCE CARRIER: U Ctvl s OL,C
YD-
WFTDAAdu1t W&R linAl DME#1807672
RELEASE AND WAIVER OF LIABILITY ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that 1 am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH,("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions, the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUET the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND 1 FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,IWILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees;loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ-THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF`THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING,SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME& LEAGUE NAME: �U`�nP-S " �--�tnv l /
PARTICIPANTS SIGNATURE: L� ��t A
ADDRESS: C t� C 90 t,-J
f(Street)(� (Clty) (State) (Zp)
PHONE: J`� 1 6 O DATE:
PRIMARY HEALTH INSURANCE CARRIER: li CI �� r (i L'A
WF FDA Adult W&R 10111 DME#IM672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"), I,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, 1 believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks");(b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES 1 incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERA13ONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTIO$OF RISK,AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I'WILL INDEMNIPY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss,liability;damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL. LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF,'kTHS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULtTORCE AND EFFECT.
S1 PRINT NAME LEAGUE NAME: �V L ! n -/-
Vi 1 1 ,, / "t,R:iAD THIS R J� 1'1
PARTICIPANTS SIGNATURE:
ADDRESS:
J `(S]treet) (City) State) (zip)
PHONE: " 6 O Vl + 1 O ~ DATE: —��
PRIMARY HEALTH INSURANCE CARRIER: ���lti e ✓VI ( � l^'t
WFTDAAduRW&R IMAI DME N1807672
RELEASE AND WAIVER OF LIABILITY ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR M,PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ'T14IS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND T14AT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS- AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING,SHALL CONTINUE IN FULL FORCE AkjD EFFECT.
PRINT NAME& LEAGUE NAM bA aE se S
PARTICIPANTS SIGNAT
ADDRESS: 1 qz2j
(street) (City) \( ate) (zip)
PHONE: SOO Y`1 CA `tiu Q I DATE:
PRIMARY HEALTH INSURANCE CARRIER: lea` ,- (k Ymc.rtivl�c
WFTDAAdua W&R 10111 DME#1907672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
1N CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"), 1, for myself,my personal representatives,assigns,heirs, and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES"NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of-Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS, AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf, makes a claim against any of the RELEASEES TWILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALLLIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: �2V11 itat Y�(�cafY j 5
PARTICIPANTS SIGNATURE:
ADDRESS:
(Street) j (CO) (State) (Zip)
PHONE:�?ko 1331; 91-0`9 DATE: 0l2 I's
PRIMARY HEALTH INSURANCE CARRIER: V�(lt
WFTDA Adult W&R 1 nin DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"), 1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks"); (b) these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss, liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT 1 HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF, TkIIS`AGREEMENT IS 14ELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: TA46L ]�dlIAVEAEADASVLE NSA A9
PARTICIPANTS SIGNATURE:
Lni �l g9 11 1 y� ��1 fin
ADDRESS: �LQA t 1n6 �aC �IJY a >r \ CA-
(Street) (City) (State) (Zip)
PHONE: }�D1 )q--6 ei5 DATE:
PRIMARY HEALTH INSURANCE CARRIER: aCc�eG+\ru ( yQ ` wJj� jyti
WP DAAduMw&R_ 1117/11_ _ ..,___.. DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISKS
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives, assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH('.'Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in,the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES,COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE' the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, oilier participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I W-ILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME:Uxu G' �1 t msIcEACE V, y,)C,��W
PARTICIPANT'S SIGNATURE: n
ADDRESS: �t9�I D A Ol\k-u a3 �
(Street) (City) (State) (Zip)
PHONE: 6 10�cn ( � P)LO 0 DATE: I I (P I
PRIMARY HEALTH INSURANCE CARRIER:
WFTDAAAult W&R I1]/11 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time; I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH('Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES"NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SCTE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,'DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attomeyfees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
1 ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITYTO THP GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME:
PARTICIPANTS SIGNATURE: G /1
ADDRESS: U k7k
(Street) C (city) (State) (zip)
PHONE: �O ` 0 Dy 7
tr f DATE:
PRIMARY HEALTH INSURANCE CARRIER: LJL W / Z?D
WPrDAAduIt W&R 1117111 DME01807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS .AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH-("Risks");(b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating`inthe Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR 1�FART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERA7It)NS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
1 ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT i HAVE GIVEN UP SUBSTANTIAL RIGHTS BY•SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR.ASSUR:ANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OIL ALL 'LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF„„? RS'-AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN,Ft1LL'F�k3RYC1E AND EFFECT.
PRINT NAME&LEAGUE NAME:
PARTICIPANT'S SIGNATURE: r—
rr11
ADDRESS: 0�IiV J �' S 1 ZOO
(Street) (City) (State) (Zip)
PHONE: -7(oy Co (n O - O O' !� DATE:
PRIMARY HEALTH INSURANCE CARRIER: Se,�
WFTDAAdnRW&R IVMI DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1, for myself,my personal representatives, assigns, heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES"NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,'DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISC,AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE TI4AT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING,IS14ALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME& LEAGUE NAME: *kIA PFAD TPIIS RELEASE
PARTICIPANTS SIGNATURE: ctt /
ADDRESS: r ,&z 2c�7V ( T4 9,,v35
(Street) (City) / (State)- (Zip)
PHONE: :?ko - ad - 0 0L -�- DATE:
PRIMARY HEALTH INSURANCE CARRIER: l_.{�t ueue Nt ct CA ASS
WFTDAAduIt W&R INl11 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),I, for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that 1 understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating,in the Activity, the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES `COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SIZE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, othe€participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is`-conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATli3NS;AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK IAND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss,liability,,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT 1S HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL:CONTINUE IN-FULL FORCE AND EFFECT.
PRINT NAME& LEAGUE NAM15:72 a o i ys
PARTICIPANTS SIGNATURE:
ADDRESS: =iN n `San yS fin n1r o traA Q -*t.0 /•} 277 3 GI
(Street) (City) (state) (Zip)
PHONE: —A�a tAl<�, DATE: (�—
PRIMARY HEALTH INSURANCE CARRIER:
WFTDAAduk W&R I1f7/11 DME N1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives, assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree, and represent that I understand the nature of this Activity,and that I am qualified,in good health,
and in proper physical condition to participate in such Activity. I farther agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS:AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE, the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, )ANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND 1 FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF, THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTW11THSTANDING,SHALL CONTINUE IN FULLEORCE AND EFFECT.
PRINT NAME& LEAGUE NAME: 1��1�UI(/� TC#9k &p Tars RF
LEnsc FfJI •V� ' U '�t`Wtt �i S
PARTICIPANTS SIGNATURE: ll y�
P J?t \ G �V lt/� Cyr �ZZ �3
ADDRESS: t ]w � L�`
(Street) (City) (state) (Zip)
PHONE: GCS- 1 — e 4 DATE: I ((-Of 15
PRIMARY HEALTH INSURANCE CARRIER: !/1Af t A/ Q4-A) �&&M UAk t
WFTDAAdWt W&R 1117111 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives, assigns,heirs, and next of kin:
1. ACKNOWLEDGE,agree, and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SIDE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS, AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, A14D INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES 1 WILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND 1
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY.PORTION Of j*S AGREEMENT IS HELD TO BE
INVALID, THE BALANCE,NOTWITHSTANDING,SHALL CONTINUE IN FUELFORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: / ttddff
PARTICIPANTS SIGNATURE:
ADDRESS: �S �S3 (p*OIL (/ �( r
(Street) (City) (State) (Zip)
PHONE: a6 �7 3 Z(06 DATE: /r, /,J'
PRIMARY HEALTH INSURANCE CARRIER: I19�G�L1>
WFTDAAduk W&R 11n111 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
1N CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1, for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that I understand the nature of this Activity, and that I am qualified,in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is,conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,_TWILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss,fiabilty,damage, or cost which may be incurred
as the result of such claim.
1 ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL- RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION"OF THIS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE INFULLFORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: ( e"
PARTICIPANTS SIGNATUR
ADDRESS: t Y
(( (Street) i (city) ` (State) (zip)
PHONEk:14U) (09 G- y � DATE: V__ `S
PRIMARY HEALTH INSURANCE CARRIER:
WFrDAAEURW&R 11n/ll DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"), 1,for myself, my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree, and represent that 1 understand the nature of this Activity,and that I am qualified,in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES,COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, respue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS;,AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ-'THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF,ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE,NOTWITHSTANDING,SHALL CONTINUE`f''f���AAIN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: DA n Ab V�HM.a-1f4 ALEASE
PARTICIPANTS SIGNATURE:
ADDRESS: -1 _ G(l 5; Lo WI V) CI- (4-025 3
(Street) (City) (State) (Zip)
PHONE: 00 (7 35�11 DATE: � '?31 I`>
PRIMARY HEALTH INSURANCE CARRIER: 101 ` r tX1 I• t CAfe,
WMAAdultWAR 11M111 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in W omen's Flat Track Roller Derby
("Activity"), I,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree, and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other.participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR I�RAttT BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPER?4 OI ; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: NA G OY I A. 1 rt ra" LEASE ev 61 7
PARTICIPANTS SIGNATURE: � �
ADDRESS: 33)75 O A + t' d `v`-r &MIU lD( ' 0& q�Z3�
(Street) (City) J (State (Zip)
PHONE.--AQ q1D' ,'YZ10 DATE:
PRIMARY HEALTH INSURANCE CARRIER:
WMAAM W&R I1n111 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives, assigns,heirs, and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES"NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss, liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME..ez C� Jy vE sq a6fi1�t L A9C�
PARTICIPANT'S SIGNATURE: W
ADDRESS:1-D l0 &9� D� DV'4' /�• ( /1"r. I v
r (Street) (City) (State) (Zip)
PHONE: Q I v` 0 -1?9 3-� DATE:
PRIMARY HEALTH INSURANCE CARRIER: � LA P C Wo 1 a—
WFTDAAdNIt W&R IM111 DMEN19076M
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1, for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks");(b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating;n the Activity, the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT 1 AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP' SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL.LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF TW'AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULLFORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: Ill(C '� sxFn a
PARTICIPANTS SIGNATURE:
ADDRESS:_ "ELM2, 01T-
(street) (City) (Zip)
PHONE: ' '1 �tI I� LUS DATE:
PRIMARY HEALTH INSURANCE CARRIER:
WFTDAAd"a W&R_ 10/11 _ DME A180767E
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,
AND 1NDENINITY AGREEMENT
("Agreement")
1N CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derbx
("Activity"), I, for myself.my personal representatives, assigns,heirs, and next of kin:
1. ACKN'ONY LEDGE, agree,and represent that f understand the nature of this Activity, and that I am qualified. in good health.
and in proper physical condition to participate in such Activity. I further agree and warrant that if at anv time. I bclic%e the
conditions to be unsafe. I gill immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS A(LAIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
IN IL R) . INCLLDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("Risks"); (b)these Risks and dangers may
he caused by my own actions or inactions, the actions or inactions of others participating in the .Activity,the conditions in which
the Activih takes place. or THE NEGLIGENCE OF TIIE "RELEASEES" NAMED BELOW: (c) there may be OTHER RISKS
or SOCIAL AND FCONOMIC LOSSES either not known to me or not readily foreseeable at this time: and I FULLY ACCEPT
_AND ASSI;Mf: ,ALL SL('H RISKS AND ALL RESPONSIBILITY FOR LOSSES. COSTS. AND DAMAGES t incur as a
rr.ult of niv participation. in the Actik n%.
3. HEREBN RELEASE, DISCHARGE, AND COVENANT NO-1 TO SUE the sanctioning organization(s), their
udminisrrators. directors. agents. officers, members, yoluntecrs, and emptoyces, other participants. officials, rescue personnel.
sponsors, adeertiscrs, owners and lessees of Premises on which the .Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES. OR DAMAGES ON
MY Acuot.Ar CAUSED. OR ALLEGED TO BE CA(.SED. IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RLLEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I I UR114ER AGREE that if.
despite this RELEASE AND AVAIVFR OF LI.ABIL-11) . ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
,mnonc on my behalf. makes a claim against any of the RELEASEES, I WILL INDEMNIFY,SAVE, AND HOLD I-
(ARMLESS
EACH OF THE: RELEASEES trom any litigation expenses. attorney fees, loss, liability,damage. or cost which may be incurred
as the insult ol'such claim.
t AC'KNO%kLEDGE THAT I AM OVFR THE AGE OF IR YEARS. HAVE READ THIS AGREEMENT AND FLLLY
L-NDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BN SIGNING IF,
HAA E SIGNED IT FREELY AND WITHOUT :ANY IN'DLCEMENT OR ASSURANCE OF ANY NATURE. AND I
INTFND T B 11 o E N A COMPLETE AND LCONDITIONAL RELFASE OF ALL LIABILITY TO THE GREATEST
I.STLKf ALLOIV'ED BY LAW AND AGREE TITAT IF ANY POR"(ION OF THIS AGREEMENT IS HELD TO BE
IS\ ALH),I HE BALANCE. NO`I WITHSTANDING. SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME:
JI
PARTICIPANTS SIGNATURE: .t
ADDRESS: "� �y'� C`s�ti �U}>,�, � 6� �� i,G.1-.�
}} (Street) pp (0ty) (State) (Zip)
PHONE: tL4 i 1 )?`'ter - Ltc 0 DATE:
PRIMARY HEALTH INSURANCE CARRIER:
tt FI11\Adult t%&R 11.711 IMF.�1807672
RELEASE AND WAIVER of LIABILITY, AssumP"LION OF RISK,
AND INDEIINFUI AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in anv uay. at any time. in Womcn's Flat Truck Roller Derbv
t 'Actic i ty"f. I. for my.elf. my personal representatives, assigns, heirs, and nest of kin:
I. :ICKNOII-LEDGE, a_rec. and represent that I understand the nature of this Activity. and that I am qualified, in good health.
aneE in proper physical condition to participate in such Actin ity. I further agree and warrant that if, at any time, 1 believe the
conditions to be wtsafe. I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS AC-11b11Y INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INlCRY. INCLUDING PERMANENT DISABILITY', PARALYSIS.AND DEATH ("Risks"): (b)these Risks and dangers may
he cau>ed by me own actions or inactions, the actions or inactions of others participating in the Actieity, the conditions in whidt
the Acth in,takes place, or I HE NEGLIGENCF. OF THE "RELEASE:LS" NAMED BELOW: (c) there may be OTHER RISKS
or SOC[.AL ,AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time:and I FULLS ACCEPT
AAD ASSLMF. ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES. COSTS, AND DAMAGES 1 incur as a
result of nt} participation, in the Actieity.
3. HEREBI RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
adnninistraArrs, directors. agents, officer,, members, volunteers, and employees. other participants, officials. rescue personnel,
sponsors. adN ertisers, owners and lessees of Premises mn which the .Actieity is conducted. (each of the forgoing shall be
eonsidcrcd one of the RELF.ASFES herein) FROM ALL LIABILITY. CLAIMS, DEMANDS, LOSSES. OR DAMAGES ON
MY ACCOUNT CAUSED. OR ALLEGED TO 13E CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF HIE
RE LLASEF:S OR OTHERP ISE, INCLUDING NSCiLIGLN I RESCUE OPERATIONS; AND I FLRTIIER AGREE that if.
despite. this RELEASE AND VVAIVF.R OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
amanc on me behalf:makes a claim aeainst anv of the RELFASEES, I WILL INDEMNIFY,SAVE, AND HOLD HARMLESS
1:\CH OI,TIE REL1 ASFES from any litigation expenses. attorney fees, loss, liability, damage, or cost which may be incurred
a, the result of such claim.
I ,ACKN0AV'LED6L IIIA1 I ;AM OVER IHE ;AG[ OF IS YEARS, HAVE. READ THIS AGRF.EMF:NI AND FULLY
LNDERSI:AND ITS TERMS. LNDL:RSIAND IHA"F f HAVE GlA`EN' UP SUBSTANTIAL RIGHTS BN SIGNING I_
ILA%L SIGNED IT FREFLl' AND WITHOL:T ANY INDLCIiMENT OR .ASSURANCE OF ANY NATURE_ .AND I
INTEND IT TO Bf: A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EVIENT ALLOV%ED BY LA\k .AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INA ALID. THE BALANCE, NOTWITHSTAND[SG,SHALL CONTINLF, IN FULL FORCFi. AND FFFFCT.
PRINT NAME& LEAGUE NAME.
PARTICIPANT'S SIGNATURE: ^ '`
IJ
ADDRESS: V U' V Ll�L1/� W Uyfl rl+ C/ j ql�
� )
(Street) + '�— (City) (State) (ZIP)
PHONE: 3)b �!� DATE:
PRIMARY HEALTH INSURANCE CARRIER: Vti
w —
%N r10:N U.11 NaN n,.n TIME e181g6';
RELEASE AND WAFk ER OF I.IABlixi-i.AssUMPTION OF RISK.
AND INtwvtNITY AGREEMENT
("Agreement")
IN CON SI DFR.ATION of being permitted to participate this date. in any way, at anytime. in Womerf s Flat I rack Rollcr Derby
I"4ctiein' 1. I. for tmreclf my personal represcntativcs. assigns, heirs, and next of kin:
1. ACKNOIYL.EDGE. agree, and represent that I understand the nature of this Activity, and that I am qualified, in good health.
and in pnlper physical condition to participate in such Acticit}. I further agree and warrant that if. at any tiote, I belieNe the
condition, to he unsafe, I gill immediately discontinue further participation in this Activity.
2. FLI.LI UNDERSTAND that la) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOLS BODILY
IN IL RY, IN( Lt:DING PERMANENT DISABILITY, PARALYSIS. AND DEATH ("Risks"); (b) these Risks and dangers may
be caused by my own action, or inactions, the action, or inaction.of others participating in the Activity. the conditions in which
the Adimity takes place. orTHF NEGLIGENCE OF THE. 'RELEASEES" NAMED BELOW: (c) there may be OTHER RISKS
or So ( I:AL :AND ECONOMIC LOSSES either not known to me or not rcadik foreseeable at this time: and I FULLY ACCEPT
AVI) ,\SSLNIL ALL SLCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, .AND DAMAGES I incur as a
rsuil of my participation. in the Ac(icity.
J. HE:REII) RELEASE. DISCHARGE, AND C'ONENANF NOT TO SUE the sanctioning organization(s), their
.undo istrlton. dirclor,, agents. officers. member,. Volunteers, and employees. other participants. officials_ rc�CUC perxnumcl.
slamsors. ad,-cltl.crn. owners and lessees of Premises on which the Activity is conducted. (each of the forgoing shall be
amsider:d one ofthe RF,LL:VSH- hcreim FROM ALL LIABILITY. CLAIMS, DEMANDS, LOSSES. OR DVNIAGES ON
NI% ACCGLNT CAUSED. OR ALLEGED TO [if CAL:SED, IN WHOLE OR IN PART BY TILL NEGLIGI�NC F: OF TEl17
RLLi_ASEES OR O"FHFR%V ISF, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that it,
Lc,ptr this RELEASE :AND W'AI% TR OF LIABILITY ASSUMPTION OF RISK, AND INDEMNITY" :AGRE I MEN 1 1. or
ikov'e on my behalf: makes a claim against any otthe RLL LASEES, l WILL INDEMNIFY, SAVE. AND HOLD HARMLESS
EACH OF THE RELEASFI S from any litigation expenses, attorney fees, loss, liability,damage. or cost which may be incurred
as the result of iuch claim.
I ACKNOAALEDGI IIiA"F I AM OVER THE AGE OF I YEARS. HAVE READ THIS AGREEMENT AND FULLY'
LADERSI AND I"IS TERMS. UNllERSTAND MA] I HAN1 GIVEN UP SUBSTANTLAI_ RIGHTS BY SIGNING IT,
IIAVL SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY' NATURE. AND I
IA IFM) FF TO BE A C'O'vtPLE7E AND LM ONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
I XI ENT ALLOAVED HY LAW AND AGREE TH AT 11; ANY PORTION OF THIS AGREEMENT IS HELD TO BE
IN\ .ALID.THF. BALAN('E, NOTW[THS-FANDING. SHALL CONTIXUF IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: Ent 1U
PARTICIPANT'S SIGNATURE: 1
ADDRESS: Zow) Go / Clue N, �rr1 SDnt^CAS CA `1 ZZ�c�
(Street) City) (Va ) (Zip)
PHONE: (LZ)5 3yt-i 0 Z- DATE: Z- 7 - L� —
PRIMARY HEALTH INSURANCE CARRIER:
1%1-11)% %du It NdR 11'll Dtilr.a190'6]!
RELEASE AND WAIVER OF LIABILI11,ASSUNIPTION OF RISK,
AND INDEN'INIT\ AGREENIEN'T
("Agreement")
IN CONSIDERATION' o1 being permitted to participate this date.in any way.at any time.in Womcn's Flat Track Roller Derb\
(".Acti%m"). 1. for rnysclf,my personal representatives. assigns. heirs. and nest of kin:
L ACKNOAVLEDGE.agree, and represent that I understand the nature of this Activity. and that 1 am qualified, in good health.
and in Proper physical condition to participate in such Activity. I further agree and warrant that it; at anv time. I believe the
Conditions to be unsalc. I .N ill immediately discontinue further participation in this Activity.
Z. FULLY UNDERSTAND that: ta) THIS A( LIA'11,Y INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
IN.IURY. 1ACLLDISG PERMANENT DISABILITY, PARALYSIS. AND DEATH ("Risks"): (b) these Risks and dangers ntay
h m e caused by y oven actions or inactions, the actions or inactions of others participating in the Activity, the conditions in which
file Activity takes place, or THE NEGLIGENCE OF THE 'RELEASEES" NAMED BELOW: (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readilc foreseeable at this time; and I FULLY ACCEPT
VAD ASSLVIE :ALL SCC.I] RISKS AND .ALL RESPOASIBILITY FOR LOSSES, COSTS. AND DANIAGES 1 incur as a
result ul me participation. in the Activity.
3. HF,REBI RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organizationts), their
atlntinistrator., director:. agents, otlicers, members, vuluntecrs, and employees, other participants. officials. rescue personnel,
aponsor_s, advertisers. o"ners and lessees of Premises on which the Activity is conducted. (each of the forgoing shall be
considered one of the Rt LEASELS herein) FROM ALL LIABILTFY,. CLAIMS. DEMANDS. LOSSES_ OR DAMAGES ON
M)' ACCOUNT CAUSED. OR ALLEGED TO BE C'ALSFD. IN WHOLE OR IN PART BY THE \EGLIGEWE OF THE
RELLASEES OR OTHERWISE, INCLLDING NFGLIGE.NT RESCUE OPERATIONS: AND I FURNIER AGREE that if.
&,pits this RELEASE AND WAIVER OF LIABILITY, ASSU1,1PFION OF RISK, AND INDEMVI )' AGRLEA-LENT 1. or
anvune on my behalf, rnake, a claim al,ainsram of the RTLF.ASEES.I WILL INDEMNIFY, SAVH,AND HOLD HARMLIiSS
EACH OF TFIE RFLE ASI LS from any litigation expenses. attomev fees_ loss, liability, damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT [ AM OVER THL AGE OF 13 YEARS. HAVE READ THIS AGRLEN1ENT .AAD FULLY
I _ADERSTA\D ITS TERMS, UADERS'I AND THAT I HAVE GIVEN LP SUBSTANTIAL RIGHTS BY SIGNING IT.
HAVE SIGNED IT FREELY AAD WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE. .AND I
INTEND 1'I 'TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIAB[L[TY "TO 'TFIE GREATEST
FATFNT :ALLOWED BY LAN= AND AGREE THAT IF ANY PORTION OF THIS AGREEMENf IS HELD TO Btu
]NV"SLID. 11LE BALANCE.. NOTW'I'THSSTANDING. SHALL CONI [A't;E IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: 10C'�:(dr�4`'rl {I<dirl
PARTICIPANT'S SIGNATURE:
ADDRESS: L � ) >� Cy. _YLiVZC( �Cv1 f.T Ly1 ` C,f n�'t;ri (, tl t��<<'j
(Street) (City) { (State) (Zip)
PHONE: >`( �3'�S ` (�J �( DATE:
PRIMARY HEALTH INSURANCE CARRIER:
"FI"A Wait"4K it 7ll DVF.atRIf;M'_
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement')
IN CONSIDERATION of being permitted to participate this date. in am way, at any time, in W'omen's Flat Track Roller Derby
("Activity-'). 1, for myself. my personal representatives. assigns, heirs. and next of kin:
I. ACKNOWLEDGE, agree.. and represent that 1 understand the nature of this Activity, and that I am qualified. in good health.
and in proper physical condition to participate in such Activity. I further agree and «arrant that if. at any time. I beliete the
conditions to be unsafe. I will immediately discontinue further participation in this Activity.
2. FULLY LNDERSTAND that: (a) THIS AC"IIVIIV INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
IV JURY. INCLUDING PERMANENT DISABILITY. PARALYSIS. AND DEATH ('Risks"): (b) these Risks and dangers may
be caused by mg own actions or inactions,the actions or inactions of others participating in the Activity. the conditions in which
the Activity takes place.or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time: and I FULLY ACCEPT'
AND .ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES. COSTS. AND DAMAGES 1 incur as a
result of my participation. in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM .ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED. OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE. that if.
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMEN"1 I, or
amone on my behalf. makes a claim against any of the RELFASFES, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS
EACH OF THF. RF_LFASFES from any- litigation eNpenses. attorney fees, loss, liability, damage, or cost which may be incurred
as the result of such claim.
I AC(INOWI_LG H M DE THAT I A OVER THE AGE OF IR YEARS. HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND IFS TERMS, UNDERSTAND THAT I HAVE- GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IF.
HAVE SIGNED IT FREELY AND WITHOUT ANY INDU(,EMENT OR ASSURANCE OF ANY NATURE_ AND I
IN-FEND 11 TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
F%A AI_ID, THE BALANCE,NOTWfFHSTANDING. SHALL CONTINUE IN FULL FORCE AND EFFECT.
,Fz—
PRINT NAME&LEAGUE NAME:
PARTICIPANTS SIGNATURE:
�!
ADDRESS:
(street) (City) (stare) (zip)
PHONE: ' �� DATE:
t i
PRIMARY HEALTH INSURANCE CARRIER:
�crnr„nm,resa n:-ni t»te axn+s+_
FACILITY USE AGREEMENT
(COACHELLA VALLEY DERBY GIRLS)
This Facility Use Agreement ("Agreement") is made and entered into this day of
ULWW 201 a- , by and between the City of Palm Springs ("City") and
Coachella Valley Derby Girls ("CVDG") concerning the use of the Demuth Community Center
("Facility").
RECITALS
WHEREAS,the City and CVDG are mutually interested in providing needed amenities and
community services to all residents of Palm Springs; and
WHEREAS, through this agreement, CVDG will be afforded the opportunity, on the same
basis as other lawful users, to provide services, including sports and recreation activities desired by
the community; and
WHEREAS,CVDG now desires to enter into this Agreement to obtain access and use of the
Facility, according to the terms and conditions stated herein.
NOW, THEREFORE, the City and CVDG do hereby mutually agree as follows:
AGREEMENT
1. TERM.
1.1. Term. This Agreement shall be in full force and effect for a period of one(1) year,
beginning July 1, 2013 and ending June 30, 2014. City and CVDG may renew this Agreement for
two (2) additional one(1) year terms, under the same terms and conditions stated herein,except for
any changes such as fees and charges for the use of certain facilities as specified in Section 2.
1.2. Termination. City and CVDG may terminate this Agreement at any time, with or
without cause,upon sixty(60)days' written notice to CVDG. Nothing shall prohibit termination at
less than sixty(60) days' written notice upon any material breach of this Agreement.
2. FACILITY USE.
2.1. Facility Use. City grants CVDG the use of the Gymnasium, as identified in Exhibit
"B", and subject to the rules and regulations outlined in Exhibit "A". The Facility, and the areas to
be used by CVDG, are more specifically described in the attached Exhibit "B" and incorporated
herein by reference.
2.2. Scheduling of Use. CVDG may use the Facility in accordance with Section 1.1 only
during the times specified in the Schedule, attached as Exhibit "C" and incorporated herein by
reference. The City may, in its sole discretion, alter the Schedule in order to maximize use of the
Facility for all users.
2.3. Fees and Charges for Facility CVDG agrees to pay City One Hundred Dollars
(S 100.00) monthly, on or before the fifth of every month, for the use of the Facility. An additional
ORIGINAL BID
772567A 1 ANWOR AGREEMENT
late charge of$35 shall be due on all payments received after the fifth of every month.
2.4. Storage and Personal Property. Reserved.
2.5. Mailbox. Reserved,
2.6. Utilities. CVDG is responsible for establishing telephone lines, in separate accounts
from the City, and is responsible for payment of monthly accounts related to these services. All
other utilities shall be provided by the City. CVDG expressly waives any and all claims to the City
for compensation for any and all losses or damages sustained for any reason or any defect,deficiency
or impairment of any utility system, water supply system, drainage system, electrical apparatus or
wires serving the Facility with respect to the loss of the facility for CVDG functions.
2.7. Signs. No signs may be erected at the Facility, unless CVDG first obtains written
approval from the City. All signs posted by CVDG at the Facility shall conform to all applicable
Palm Springs Municipal Code and Palm Springs Zoning Code provisions.
3. SECURITY AND BACKGROUND CHECKS.
3.1. Background Checks. Any person having supervisory or disciplinary authority over
any minor is required to obtain a criminal background screening in accordance with the procedures
outlined in California Public Resources Code Section 5164. Provided that CVDG maintains
requirements for skaters to be at least IS years of age, and there is no supervisory authority over
minors, CVDG shall be exempt from Security and Background Checks.
3.1.1. Supplemental Questions. Reserved.
3.1.2. Submission and Fingerprints. Reserved.
4. INSURANCE.
4.1. Minimum Insurance. CVDG shall procure and maintain,at its sole cost and expense,
in a form and content satisfactory to City, during the entire term of this Agreement, including any
extension thereof, the following policies of insurance:
4.1.1. Comprehensive General Liability Insurance. A policy of comprehensive
general liability insurance in an amount not less than One Million Dollars ($1,000,000.00) per
occurrence and in an amount not less than Two Million Dollars ($2,000,000.00) in aggregate.
Insurance companies shall have an AM Best's Guide Rating of A-, Class VII or better.
4.1.2. Workers' Compensation Insurance. To the extent required by the State of
California, CVDG shall procure and maintain workers' compensation insurance in the amount and to
the extent required by law.
4.2. Proof of Insurance. Proof of the insurance required under Section 4 shall be provided
to City prior to the execution of this Agreement.
4.3. Primary Insurance. C VDG's insurance coverage shall be primary with respect to the
City and its respective elected officials,officers,employees, agents, and volunteers. Any insurance
or self-insurance maintained by City and its respective elected officials,officers,employees,agents,
7r2567A 2
and volunteers shall be in excess of CVDG's insurance and shall not contribute with it. For
Workers' Compensation and Employer's Liability Insurance only,the insurer shall waive all rights of
subrogation and contribution it may have against City, its elected officials, officers, employees,
agents, and volunteers.
4.4. Endorsements. CVDG shall obtain an Additional Insured Endorsement designating
the City, its officers, officials, employees, agents, and volunteers as additional insureds for liability
arising out of this Agreement. All endorsements shall reference that CVDG's insurance shall be
primary and non-contributory, as outlined in Section 4.3.
4.5. Deductible. Any deductibles or self-insured retentions must be declared to and
approved by the City prior to the commencement of this Agreement. At the option of the City,either
(1)the insurer shall reduce or eliminate such deductibles or self-insured retentions with respect to the
City, its elected officials, officers, employees, agents, and volunteers; or(2) CVDG shall procure a
bond guaranteeing payment of losses and related investigations, claim administration, and defense
expenses. Certificates of Insurance must include evidence of the amount of any deductible or self-
insured retention under the policy. CVDG guarantees payment of all deductibles and self-insured
retentions.
4.6. Amendment of Insurance Policy. CVDG shall not amend, or allow to be amended,
any insurance policy under this Agreement if such amendment is not consistent with the minimum
insurance requirements contained herein. Such amendment without the consent of the City shall be
considered a material breach of this Agreement and City may immediately terminate this Agreement
upon such occurrence.
4.7. No Cancellation of Insurance Policy. CVDG shall not cancel, or allow to be
cancelled, any insurance policy required under this Agreement. If said policies of insurance are
cancelled,CVDG shall,prior to the cancellation date,immediately obtain new insurance consistent
with the requirements of this Agreement and immediately submit evidence of such insurance to the
City.
4.8. Failure to Obtain Valid Insurance During Use of the Facility. If CVDG is not
minimally insured,as required under Section 4, CVDG shall be considered in material breach of this
Agreement and City may immediately terminate this Agreement.
4.9. No Limitation. The provisions of this Section 4 shall not be construed as limiting in
any way the extent to which CVDG may be held responsible for the payment of damages to any
persons or property resulting from CVDG's activities or the activities of any person or persons for
which CVDG is otherwise responsible.
772567.1 3
5. INDEMNIFICATION AND DEFENSE.
5.1. Indemnification. CVDG agrees to indemnify the City, its officers, agents and
employees against, and shall hold and save each of them harmless from, any and all actions, suits,
claims, damages to persons or property, including injury or death to any person, losses, costs,
penalties, obligations, errors, omissions or liabilities (herein "Claims") that may be asserted or
claimed by any persons, firm or entity arising out of or related to this Agreement or CVDG activities
at the Facility, except to the extent that the Claim arises from the sole negligence or willful
misconduct of the City, its officers, agents or employees.
5.2. Defense. CVDG agrees to defend, with counsel acceptable to City, the City, its
officers, agents and employees against any Claims that may be asserted or claimed by any persons,
firm or entity arising out of or related to this Agreement or CVDG activities at the Facility,except to
the extent that the Claim arises from the sole negligence or willful misconduct of the City, its
officers, agents or employees.
5.3. Costs Associated with Indemnification and Defense. CVDG shall be responsible for
all costs incurred by the City that are associated with the indemnification or defense of City by
CVDG, including any costs associated with the use of City resources, including lost time by
employees, expended in furtherance of the indemnification or defense.
6. GENERAL PROVISIONS.
6.1. Notice. All notices,demands and requests which maybe given or which are required
to be given by any party to this Agreement, and any exercise of a right of termination provided by
this Agreement, shall be in writing and shall be deemed effective either: (1) on the date personally
delivered to the address below, as evidenced by written receipt therefore, whether or not actually
received by the person to whom addressed; (2) on the third (3rd) business day after being sent, by
certified or registered mail, return receipt requested, addressed to the intended recipient at the
address specified below;(3)on the first(1 st)business day after being deposited into the custody of a
nationally recognized overnight delivery service(i.e.,FedEx Corporation,UPS,or DHL)addressed
to such party at the address specified below; or (4) on the business day sent via facsimile
transmission to the facsimile numbers below, as evidenced by a printed confirmation of the
successful electronic transmission of the message prior to 2:00 p.m. (Pacific Standard Time), or
otherwise delivery shall be considered to be on the following business day. For purposes of this
section, the addresses of the parties for all notices are as follows:
6.1.1. City.
City Manager
City of Palm Springs
3200 E. Tahquitz Canyon Way
Palm Springs, CA 92262
(760) 323-8299
772567.1 4
6.1.2. CVDG.
Coachella Valley Derby Girls
P. O. Box 1911
Palm Springs, CA 92263
760-835-9618
CVDG shall be responsible for notifying the City, in writing, of any changes in CVDG's address.
6.2. California Law. This Agreement shall be construed and interpreted both as to validity
and to performance of the parties in accordance with the laws of the State of California. Legal
actions concerning any dispute, claim or matter arising out of or in relation to this Agreement shall
be instituted in the Superior Court of the County of Riverside, State of California, or any other
appropriate court in such county, and CVDG covenants and agrees to submit to the personal
jurisdiction of such court in the event of such action.
6.3. Waiver. No delay or omission in the exercise of any right or remedy by a non-
defaulting party on any default shall impair such right or remedy or be construed as a waiver. A
party's consent to or approval of any act by the other party requiring the party's consent or approval
shall not be deemed to waive or render unnecessary the other party's consent to or approval of any
subsequent act. Any waiver by either party of any default must be in writing and shall not be a waiver
of any other default concerning the same or any other provision of this Agreement.
6.4. Rights and Remedies are Cumulative. Except with respect to rights and remedies
expressly declared to be exclusive in this Agreement, the rights and remedies of the parties are
cumulative and the exercise by either party of one or more of such rights or remedies shall not
preclude the exercise by it, at the same or different times, of any other rights or remedies for the
same default or any other default by the other party.
6.5. Legal Action. In addition to any other rights or remedies, either party may take legal
action, in law or in equity,to cure,correct or remedy any default,to recover damages for any default,
to compel specific performance of this Agreement, to obtain declaratory or injunctive relief, or to
obtain any other remedy consistent with the purposes of this Agreement.
6.6. Attorney's Fees. If either party to this Agreement is required to initiate or defend or
made a party to any action or proceeding in any way connected with this Agreement, the prevailing
party in such action or proceeding, in addition to any other relief that may be granted, whether legal
or equitable, shall be entitled to reasonable attorneys' fees. Attorneys' fees shall include attorneys'
fees on any appeal, and, in addition, a party entitled to attorneys' fees shall be entitled to all other
reasonable costs for investigating such action, taking depositions and discovery, and all other
necessary costs the court allows that are incurred in such litigation. All such fees shall be deemed to
have accrued on commencement of such action and shall be enforceable whether or not such action
is prosecuted to judgment.
6.7. Non-Liability of City Officers and Employees. No officer or employee of the City
shall be personally liable to CVDG, or any successor-in-interest,in the event of any default or breach
by the City or for any amount that may become due to CVDG or to its successor,or for breach of any
772567.1 5
obligation of the terms of this Agreement.
6.8. Conflict of Interest. No officer or employee of the City shall have any financial
interest,direct or indirect,in this Agreement nor shall any such officer or employee participate in any
decision relating to the Agreement that affects his financial interest or the financial interest of any
corporation,partnership or association in which he is directly or indirectly interested,in violation of
any state statute or regulation. CVDG warrants that it has not paid or given and shall not pay or give
any third party any money or other consideration for obtaining this Agreement.
6.9. Covenant Against Discrimination. CVDG covenants that,by and for itself,its heirs,
executors, assigns and all persons claiming under or through it, that,to the extent permitted by law,
there shall be no discrimination against or segregation of any person or group of persons on account
of race,color,creed,religion, gender,marital status,sexual preference, domestic partnership status,
national origin or ancestry in the performance of this Agreement.
6.10. Compliance with Governing Law. CVDG shall comply with all applicable laws,
codes, ordinances and regulations of the federal, state, and local government.
6.11. Interpretation. The terms of this Agreement shall be construed in accordance with the
meaning of the language used and shall not be construed for or against either party by reason of the
authorship of this Agreement or any other rule of construction that might otherwise apply.
6.12. Modification. This Agreement maybe amended at any time by the mutual consent of
the parties by an instrument in writing.
6.13. Severability. In the event that any one or more of the phrases, sentences, clauses,
paragraphs or sections contained in this Agreement shall be declared invalid or unenforceable by a
valid judgment or decree of a court of competent jurisdiction, such invalidity or unenforceability
shall not affect any of the remaining phrases, sentences, clauses, paragraphs or sections of this
Agreement hereby declared as severable and shall be interpreted to carry out the intent of the parties
hereunder unless the invalid provision is so material that this invalidity deprives either party of the
basic benefit of their bargain or renders this Agreement meaningless.
6.14. Successors. The terms and conditions contained herein shall be binding on and inure
to the parties to this Agreement,their administrators,representatives, successors and assigns,except
as otherwise provided in this Agreement.
6.15. Assi ng ment. CVDG may not assign or transfer its interest under this Agreement
without City's prior written consent, which consent may be withheld, conditioned or delayed in
City's sole and absolute discretion. Any attempted assignment,sublet or transfer made in violation
of this provision shall be void.
6.16. Venue. Any action at law or in equity brought by either party to this Agreement
regarding the subject matter of this Agreement shall be filed in the Superior Court of the State of
California for the County of Riverside, Indio Branch.
6.17. Headings. The headings used in this Agreement are employed solely for convenience
of the parties and are not to be used as an aid in interpretation.
772567.1 6
6.18. Relationship. Nothing contained in this Lease shall be construed as creating the
relationship of principal and agent or of partnership or joint venture between City and CVDG.
6.19. Authority to Enter into Agreement.The persons executing this Agreement on behalf
of CVDG warrants that they are duly authorized to execute and deliver this Agreement on behalf of
said party,and by so executing this Agreement, such party is formally bound to the provisions of this
Agreement.
6.20. Counterparts and Facsimiles. This Agreement may be executed in any number of
counterparts,each of which shall be deemed an original and all of which shall constitute one and the
same instrument. Any facsimile of the original shall be treated as an original. The party submitting
any facsimile must submit a copy of the original to the other Party within a reasonable time after the
transmission of the facsimile.
6.21. Entire Agreement. This Agreement constitutes the entire Agreement between City
and CVDG. There are no oral agreements between the parties hereto affecting this Agreement. This
Agreement supersedes and cancels any and all previous negotiations,arrangements,agreements and
understandings, if any, between the parties, and none shall be used to interpret this Agreement.
[SIGNATURES TO FOLLOW]
772567.1 7
IN WITNESS THEREOF, these parties have executed this Agreement on the day and year shown
below.
CITY OF PALM SPRINGS
j Date: �� U
David H. Ready, C' nager
ATTESTED:
Date: 7 Z�°-z�-x°�3
� ames Thompson, C=AyClerk�
APPZfr
S TO FORM:
Date: C�0/3
Dougl . Holland, City Attorney
APPROVED BY CITY ivin,l;,u�<<
COACHELLA VALLEY DERBY GIRLS Abl
Date: /20115
s, President
Date:
CY1rYj�-t ytC MIUQr-, V(ct T p
reJ)ICW}
If CVDG is a corporation, a Corporate Resolution and/or Corporate Seal is required. /f a
partnership, Statement of Partnership must be submitted to City.
772567.1 8
EXHIBIT "A"
(RULES AND REGULATIONS)
l. CVDG shall require users of the gymnasium to clean up after themselves and maintain the
gymnasium in a clean condition.
2. CVDG is responsible for maintaining the security of attendees and parked vehicles at the
Facility through its own efforts, within the scope of CVDG's use of the Facility or any
portion thereof.
3. All of CVDG's refuse and rubbish shall be removed on a regular basis at CVDG's sole cost
and expense. CVDG shall not place any rubbish or other matter outside any building within
the Facility, except in such containers as are authorized from time to time by the City.
4. No radio or television or other similar device audible outside the facility shall be installed
without obtaining in each instance the written consent of the City. No aerial shall be erected
on the roof, exterior walls or grounds of the Facility without first obtaining in each instance
the written consent of the City which consent shall not be unreasonably withheld or delayed.
Any aerial so installed without such written consent shall be subject to removal without
notice at any time.
5. No loudspeakers,televisions,phonographs,radios or other devices shall be used in a manner
so as to be heard or seen outside of the Facility without complying with the provisions of the
City s Noise Ordinance,
6. No sirens, outside paging or any type of signalization will be permitted, except approved
alarm systems.
7. CVDG will not allow animals, except seeing-eye dogs, in, about or upon the Facility.
772567.1
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EXHIBIT "C"
(SCHEDULE)
Use of Gymnasium for Roller Derby Practices
Two-Hour time slot on Mondays, Wednesdays and Fridays to be negotiated between the City and
CVDG based on current programs
Note: The City of Palm Springs may require the use of the Gymnasium for special events from time
to time during CVDG scheduled use. In the event that the City requires such use, roller derby
practice may be temporarily moved to the Large Multi-Purpose Room or to another City facility.
The City will give at least 72 hours advance notice to CVDG should this need occur.
CVDG shall not have access to the gymnasium during City observed holidays when the facility is
closed.
772567.1
Department of Human Resources
�rIFOA" Holiday Schedule — 2013
HOLIDAYS ,,
PER PERSONNEL RULE 6.4.2 AND
ASSOciATED MOU`s DL.
NE4wYEAR'DAYIMP
JANUARY 1 iil G2
MARTIN LUTNER KING JR.,DAY Lm�3�µ
THIRD
,MONDAY INJANIIARY ( "�
PRESIDENTS DAY 'r i�i t 97 va) ,2
THIRD MONDAY IN FEBR IARY - .::-� il,,�. ia', .+ "' ; 8. .. OP r=
Ila
MEMORIAL DAY '
LAST MONDAY IN tdAY �=
INDEPENDENCE DAY
JuLY4l7 AZ
Al T A
LABOR DAY
FIRST MONDAY IN SEPTEMBER '. } !'.. '9` ar M. I..
VETERANS DAY.
NOVEMBER 11
f
TMANKSGIVINGDAY -
fOURTH THUR$QAY IN
DAY-AFTER THANK&WVJNG
FOU TH FRIDAYIN Nt?�XC
CHRIST�ulA3 '
DEOEMBER 24' r
CtHRISiMASDAY- :y —
ro18ER
i - Except for those classes of employees for whom a different holiday system (e.g. Holiday in Lieu) or list is
otherwise specified, the above dates will be recognized holidays for City employees (Personnel Rule 6.4.2 and
associated MOU's).
2 - The "Observed Schedule"applies to departments and/or work groups that follow a regular Monday-Thursday
work schedule. All other Departments and/or workgroups on other schedules use the "Calendar Schedule"unless
otherwise specked.
3-Holidays that fall on a Friday under the "Observed Schedule"will be credited to the employee's Floating Holiday
Bank.
WOrd/H/Forms/Benefits-Holiday Schedule 2013 Nov 2013
{?AtMsz.
Department of Human Resources
Holiday Schedule — 2014
egg" r j'
� 7
HOLIDAYS
PER PSO LE 6 4-2 AND "�i�
AS
ASSOCIATEDCW'FED MOU'$
M1111 RAW
NEW YEAR' DAY " `
'. JANUARY 1ISM
?,Y
(IMARTOLUTHER KING JR DAY3'-
THIRD MONDAY INJANUARY
dI.
PRESIDENTS DAY
s. +pi eii7DA3'�� � .1(Yt + *
THIRD MONDAY IN FEBRUARY i,;
MEMORIAL DAY
LAST MONDAY IN MAY
INDPENDENCEDAY I r
x
DULY 4
r
LABOR DAY7r
FIRST MONDAY IN SEPTEMBER = 1,i . M.� 4, `� 1iM2 ' I. .
: :
VETERANS DAY r:gfj "`" _ ^ji a t;'
NOVEMBER 11 t .. , 'zi, il} ltt
THANIS$ONING DAY
FOURTH THURN4AY IN NOVEM@ERR
SAY AFTER THANKSGIVING i - It a "t]q
FOURTH FRIDAYiN NOVEMBE#2 `
x _.n.
CHRISfMA Ev
DEt3 24
CHRISTM,,S DAY
VECEBE25 �a: {
1 - Except for those classes of employees for whom a different holiday system (e.g. Holiday in Lieu) or list is
otherwise specified, the above dates will be recognized holidays for City employees (Personnel Rule 6.4.2 and
associated MOU's).
2- The "Observed Schedule"applies to departments and/or work groups that follow a regular Monday-Thursday
work schedule. All other Departments and/or workgroups on other schedules use the "Calendar Schedule"unless
otherwise specked.
3-Holidays that fall on a Friday under the "Observed Schedule"will be credited to the employee's Floating Holiday
Bank.
Word/H/Forms/Benefits-Holiday Schedule 2014 Nov 2013
EXHIBIT "D"
(CVDG Application Packet Form)
772567J
Coachella Valley Derby Girls
Welcome to the Coachella Valley Derby Girls (CVDG)!
The Coachella Valley Derby Girls is a non-profit organization that is operated by a board of leads heading up
different committees. We have committees such as Business, Media, Fundraising, Inter-League & Recruitment
Committee, as well as a Coach, Human Resources, and Treasurer. As a skater your membership will also include
being involved in a committee of your choosing.
CVDG's goal is to create not only a team but a sisterhood where all women feel they are equal, able to openly
express themselves, promote the sport of Flat Track Roller Derby in the Coachella Valley, and achieve their dream
of becoming a roller derby athlete.
The dues collected and monies raised through fundraising as a team, will go to reserving our practice venue,
purchasing supplies, website maintenance, merchandise, and uniforms.
We are a competitive team and our practices will be run accordingly. Our goal is to be the best of the best and
the best in the Coachella Valley! After our first team is up and running we will start a Jr. Derby League.
Revised 04/29/13
Coachella Valley Derby Girls
CVDG Requirements
All Participating Skaters must:
1. Be a female and at least 18 years of age
2. Provide a copy of valid photo ID/ Drivers License and Insurance cards if covered
3. Read and sign the CVDG Liability and Model Release and acknowledgement agreement
4. Attend at least 70%of all practices, events and community service functions.
5. Understand and accept the inherent risks of playing in the league as per the liability waiver
Heath insurance is strongly encouraged and WFTDA insurance is required.
6. Read, understand and sign code of conduct.
All Street Team, NSO's and Refs must:
1. Be at least 16 years of age (under 18 will need parental permission)
2. Read, understand code of conduct
3. Attend at least 50% of all practices, events and community service functions
4. Understand the inherent risks of being involved in the league as per the liability waiver
Heath insurance is strongly encouraged And WFTDA insurance is required (Refs)
5. Read and sign the Liability waiver and model release.
6. Complete WFTDA requirements as stated on their website www.wftda.com (refs and NSO's)
Coachella Valley Derby Girls Statement of Purpose
The Coachella Valley Derby Girls league (hereafter referred to as CVDG) exists to provide an opportunity for women in the
Coachella Valley and surrounding areas to participate in the challenging and exciting sport of roller derby.
While the league is open to all qualified participants, certain standards are enforced to maintain the integrity of the sport.
This Handbook and Code of Conduct provides a guide to those standards.
Who we are:
CVDG is the first all-female flat track roller derby league in the Coachella Valley.
CVDG was established in the summer of 2012 by Jessica "Jessi James"Jeffries with the help of Caitlin "Smiley Coyote"
Hogan. They were inspired by their love of roller derby and the lack of sport out here in the desert.
CVDG is a non- profit organization and is operated by a board of leads heading up different committees to ensure the
league is run smoothly and efficiently.
Most importantly we are a competitive sport and will operate accordingly.
We currently practice 3 nights per week and plan to bout a minimum of once a month.
Revised 04/29/13
Coachella Valley Derby Girls
Derby Names
Skaters, referees and announcers have unique names, and skaters' names are registered nationally. The website where
these names are housed is: www.twoevils.org/rollergirls. After you have been placed on a team, and have paid dues for 3
months you will be allowed to register a name.You will first need to verify that your name is available on the National
Roster. Duplicate names or names that are too similar are not allowed. Jessi James is responsible for submitting skaters'
names to the National Roster, but you will be responsible for making sure your name is available.You will also need a
number. You may choose any number that is not already being used by a CVDG league member.
Uniforms
Each team will have their own unique uniform, check with your Captain for team uniform requirements and standards. The
purchase and maintenance of a team uniform is the responsibility of each skater. Protective gear is also required.
Protective gear includes: Knee and elbow pads, wrist guards, helmet and mouth guard.
Note: Do not use any baubles, gems, decorations, or paint on your helmet or uniform that could come off during skating
and pose a hazard to other skaters. Anyone violating uniform standards may not play in a bout. Check with your Captain or
Committee Lead for team uniform requirements and standards
Here are a few places that sponsor our team and provide a discount on product from their businesses.This is a great way to
pick up your gear at a discount.
Wicked Skatewear Bruised Boutique
10% off online for Entire League 10%off full price items in store and online
DISCOUNT CODE=CoachellaValleyDG 15%off all Freshmeat packages(and free skate
http://wickedskatewear.com/ tool & mouthguard)
DISCOUNT CODE=COACHELLA10
http://www,burisedboutique.com/onlinestore/
Rudecbix Derby Warehouse
10%off online 10%off
COUPON CODE= DERBYASS COUPON CODE=CVDDG
www.rudechix.com www.derbywarehouse.com
Practices
Practice time will be used for learning drills, building endurance, and increasing skating knowledge.
Stay with the group and follow the instructions of the Coach. Show the Coach(s) respect. Notify a member of the
Medical/Safety Committee if you are unable to do particular drills due to an injury or other medical issue. Doctor's note is
required if you are going to sit out for 2 weeks or more.
We want to make the most of practice, and we want it to be challenging, fun and rewarding! If you have suggestions for
future practices please contact the your committee lead and she will bring it up to the Coach(s)
Coach(s) will be available at practice to help you learn the game of roller derby, and will assist you in equipment
maintenance and skating fundamentals.
Revised 04/29/13
Coachella Valley Derby Girls
Always wear comfortable and appropriate clothes to practice. Be sure to bring all required protective gear, skates and
tennis shoes to practice, as well as a black and a white shirt for scrimmages. This gear is required or you will not skate.
There will be off skate workouts so please wear the proper attire and shoes.
Practice is set to start at a particular time. At the start time you should be geared up and ready to go.
Remove jewelry such as necklaces and earrings, as they are a major hazard to other skaters if they fall on the floor.
There is not eating or smoking during practice time whether you are skating or not.
There are no cell phone permitted during practice time whether skating or not.
At this time CVDG will be practicing at La Quinta Park until we find a venue that is a right fit for the league. We are on
public property so all league members need to show respect to other people in the public areas and please clean up after
yourself, remove all gear and trash/recycling from the premises
At this time practices are open to the public as we are continually recruiting.
Bouts:
Our bouting season runs approximately February through November, and we usually have one bout per month,
beginning in February. However, promotional events occur year-round. Be prepared to attend these events.
All league members are expected to attend bouts in uniform, whether or not you intend to skate in the bout.
ATTENDANCE POLICY:
All skaters are required to attend 70%of all eligible league practices to be considered for a bout. Once committed to a
roster you must make the two weeks practices before the bout or you will be removed from the roster. No exceptions will
be given except sickness, vacation or work, all of which need to be cleared in advance with the Coach.
Events, fundraisers, and community service events are mandatory and also count toward eligibility for a bout. You need to
attend at least 70% unless otherwise cleared ahead of time. If you are unable to make this attendance there is always
"extra credit'for skating in your off time.
"Extra Credit" is 2 teammates skating for a minimum of 1 hour. This must be reported via phone call,text message or
message to Operations Lead.
Injured players are expected to still attend practice and pay attention as this is still an excellent learning opportunity, unless
otherwise cleared. They can assist the ref team or other areas if needed.
If you are going to have to miss a practice or event you must call the Coach, Captain or Operations Lead. No Call, No Show
will not be tolerated
In case of a game absence you need to notify the Coach or and a Lead so that you will not be assigned a job at the bout.
Revised 04/29/13
Coachella Valley Derby Girls
In the case of extended absences from practice notify the Coach and at least one other board member and if due to injury
please provide doctor's note.
Street Team must attend 50%of practices, events,fundraisers and community service events.
Dues:
Dues are$30/month due at the team meeting in the beginning of the month, but no later than the 10`h of each month.
Check or money order preferred; cash will be accepted.
Dues are due whether or not you skate. If you choose to sit out for a month you still owe that month's dues.
If your dues are not paid you won't skate.
If you dues for that month are not paid by the 10"you will not skate until they are paid. If dues are 2 months past due your
name will be removed from the roster and you will no longer receive team benefits until you are caught up. NO
EXCEPTIONS. There will also be a late fee of$1 per practice day until paid.
If special arrangements need to be made it will be up to the discretion of the team treasurer and will be kept confidential
between the individual skater and the treasurer.
Coaches, Ref's, NSO's and Street Team do not pay dues as they are doing a service for the team.
WFTDA Insurance
As a member CVDG all skaters are required to have WFTDA insurance (Women's Flat Track Derby Association
www.wfdta.com). The fee per skater is $65.00. It will need to be renewed every year. It is each member's
responsibility to pay for their WFTDA insurance; it enables skaters to be covered during practices and bouts. This
fee is due the third month of membership.
Drop In Skating:
Everyone is welcome to skate with CVDG, whether it is a skater from another team, or just someone that has a
pair of skates and wants to check it out or get a good work out. The charge for 'drop in skating" will be $5, check,
cash or money order. All drop in skaters are subject to the same code of conduct as we are and will have to sign
the necessary paperwork to join in.
Drop In Skating does not make you a team member, you will not be added to the roster and will not receive team
benefits.
Recruiting:
When recruiting or representing yourself as a CVDG League member you will be respectful to those around you, including
yourself.You will conduct yourself in a manner that will encourage the general public to view or participate in CVDG events.
No member of CVDG shall EVER have the authority to deny or discourage anyone from joining CVDG based on appearance,
race, gender, sexual orientation, creed or abilities. Anyone meeting the recruitment requirements is allowed to join CVDG
and should be encouraged to do so.
Duties of Refs, NSO's and Street Team:
Ref's : are just that referees for our roller derby league. Ref's are required to read, understand and sign the code
of conduct, pass the minimum skills test as put forward by WFTDA, pass the required certification process as put forth by
WFTDA, learn the rules and signals of the game, purchase WFTDA insurance, take necessary ref classes and clinics and
attend 50%of all practices,events, and community service events.
Revised 04/29/13
Coachella Valley Derby Girls
NSO's: our Non Skating Officials (NSO) are required to read, understand and sign the code of conduct, pass the
required certification process as put forth by WFTDA, learn the rules of the game and attend 50%of all practices, events
and community service functions. As an NSO you are the time keepers,scorers, etc of the game.
Street Team: as a Street Team member your job is to promote and recruit for CVDG. You will be passing
out and and hanging up fliers, talking to people, getting donations for raffles, you are the eyes and ears of CVDG.
Street team members can also be NSO's. You are required to read, understand and sign the code of conduct, and
0
attend 50/ of all practices, events, and community service functions.
Resignation:
Any team member wishing to resign from the team will need to file a letter of resignation with the league Secretary or
Team Operations Lead.
Minimum Skills:
Each skater and Ref is required to pass the minimum skills requirements as stated on the WFTDA website. If you
do not pass minimum skills you will not be eligible to bout.
Internet List Rules
The CVDG Facebook page, "A safe place to say it" and Yahoo group sites are currently the main form of communication for
the league. If you are unable to access this site on a regular basis, be sure to notify your Leads to ensure you are receiving
the information.
Expressing of Grievances
The CVDG sites(mentioned above) are not a forum for venting your frustrations about another player, your team, or your
league. Please use the Grievance Procedure to mediate your conflict.
Email, Message, Posting and Thread Content
The primary purpose of these sites are to share league and general roller derby info, be helpful and encouraging to your
derby sisters. Please post about anything/everything derby-related including questions, tips, ideas and events. Do not post
Joke of the Day, political forwards, etc.
You are welcome to make useful or needful non-derby-related posts (announcements, parties,job-postings, requests, etc)
with the requirement that you pre-fix the subject line of the post with the words "NON-DERBY". For example: Subject:
"NON-DERBY: Anyone know a good chiropractor?"
Consequences
Abuse of the CVDG sites can result in removal from the group and/or other disciplinary actions. See the Grievance
Procedure for information on handling issues or grievances.
Revised 04/29/13
Coachella Valley Derby Girls
Code of Conduct
The following code of conduct is designed to encourage and nurture the league's unique and empowering culture.
B g q P g
The attitudes of league members have a significant impact on the league's success and reputation in the community. In
order to maintain a positive reputation, CVDG members are expected to display professional conduct whenever
representing or discussing CVDG in public. This means always presenting a positive face for the organization as well as the
sport of roller derby in general. While this is by no means a gag order, the success of the league depends on a strong,
unified public image.
We cannot stress enough the importance of using the league's democratic structure to seek change.
The league will continue to improve only if the women involved work in a cooperative and respectful manner.
Of course, getting EVERYONE on the same page is at best, a utopian ideal. There will be differences, and democracy
requires compromise. We ask that league members get involved in decision-making, and if conflicts arise, that they follow
the structured Grievance Procedure outlined in this handbook.
Any aggressive threatening comments or behavior will not be tolerated. Violation may be grounds for suspension or
expulsion. What happens on the rink stays on the rink. More importantly, what happens OFF the rink STAYS OFF the rink!
Practice conduct for skaters:
Any skater that is disrespectful to another person and/or makes demeaning remarks to another person at practice will be
asked to remove their skates for the remainder of that practice and remain at that practice, as well as the next practice.
If a skater incurs a 2nd violation the punishment will be 4 practices off skates and expulsion from the next eligible bout.
If a skater incurs a 3rd violation the punishment will be 6 practices off skates and expulsion from the next 2 eligible bouts.
If any skater loses their temper and leaves a practice without clearing it with the coach this will result in the following
disciplinary action:
First offense will result in the next 2 eligible practices off skates.
Second offense will result in 4 practices off skates.
Game day conduct for skaters:
Players who cannot control their tempers or conduct themselves in a positive manner will be given ONE verbal warning by.
If player continues after being given a verbal warning they will be expelled from the remainder of the bout immediately.
Said player will also have to write a letter of apology to her league as well as opposing league if applicable.
Said player must also attend the next 2 practices off skates.
All league members will refrain consuming alcoholic beverages before and during all CVDG bouts, scrimmages and
practices, whether or not they are on skates. At the after party and during non-skating league functions all league members
are expected to maintain control of their drinking. Failure to do so will result in disciplinary action.
Sexual Harassment Policy
CVDG is committed to providing an environment free of unlawful harassment.The league maintains a strict policy
prohibiting harassment of all forms.This policy applies to all CVDG skaters and volunteers. Harassment in any form,
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Coachella Valley Derby Girls
including sexual, verbal, and physical harassment is expressly forbidden. Sexual harassment includes, but is not limited to,
making unwanted sexual advances or requests for sexual favors, sexually motivated physical contact, or other verbal or
physical conductor communication of a sexual nature where:
a) submitting to such conduct is made an explicit or implicit term or condition of participation in league-related events;
b) submission to or rejection of such conduct by an individual is used as a basis for any decision affecting that individual; or
c) such conduct has a purpose or effect of substantially interfering with an individual's performance or creating an
intimidating, hostile or offensive environment. Hostile environment sexual harassment occurs when continued
participation in the league is conditioned upon an individual adapting to an environment where that individual is the target
of repeated, unwelcome, sexually derogatory remarks or physical contact of a sexual nature. The hostility of that
environment is judged from the perspective of the victim.
Any volunteer or skater who believes that she or he has been harassed or has witnessed harassment should report the
incident to the Coach or Captain or any member of the Board of Leads. Any Captain who receives a complaint must
immediately report any incidents of harassment to a member of the Board of Leads. The Board of Leads will investigate all
claims and take appropriate action, up to and including removal of individuals from the league.
Non Compete Clause
While participating as a member of Coachella Valley Derby Girls (CVDG),you will not participate with another roller derby
league. You agree to not be a member of, train, assist or game bout with another roller derby league unless given
expressed authorization from the Board of Leads.
Non Disclosure
While participating as a member of CVDG you will not discuss any CVDG matters, including but not limited to practice
schedules of closed practices, strategies for practices or games, policy and procedures, financials and all other CVDG
business matters with anyone outside of CVDG.
Grievance Procedure
The physical and emotional safety of skaters both on and off the rink is vitally important to the league,the skaters,and the
sport of roller derby. If at any time a skater becomes aware of an action or incident that jeopardizes the CVDG league, that
violates any of the rule in this Handbook, Code of Conduct or the Bylaws,or that harms a skater in any way;that skater is
entitled to invoke the league's grievance process. This process is designed to provide a formal structure for the voicing and
hearing of complaints.
ALL grievances must follow applicable grievance procedure, however not all grievance procedure may apply to all
grievances. It is at the discretion of the Leads, to decide which, if any, procedure is to be followed. The goal of the Leads is
to address all grievances within one week of receipt. The grievance process consists of the following steps, to be followed
in the order listed when applicable:
1)The skater should first attempt to privately address the issue with the person with whom the grievance is directed.
2)The skater may approach their Captain or relevant committee lead and ask for an informal mediation of the complaint.
The Captain or committee lead will work with all parties to resolve the dispute in a private hearing.
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Coachella Valley Derby Girls
3) If the dispute is not resolved through informal mediation, either member may submit a formal written grievance to the
Operations Lead. The proper procedure is as follows:
a.The grievance should state the specific complaint and desired course of action.
The grievance should contain any evidence backing such complaint including, but not limited to, emails or other
written correspondence. Consideration of`feelings'will betaken on a case-by-case basis.
b. Anonymous grievances may be filed when the following requirements are met:
ALL grievances and exhibits must be accompanied by the name of the
complaintant or whomever composed the submitted material. Anonymous
grievances may be filed upon request of the complaintant, however a name must
be attached for tracking and interviewing purposes for use by the only. The
Operations Lead also has the authority to conceal the identity of a complaintant when deemed
appropriate.
c. ALL grievances should be submitted to the Operations Lead, however, they can be submitted to the lead the
complaintant is most comfortable with.
d. The Operation's Lead will provide the opposing party(s)with a synopsis of the grievance.
e. The opposing party(s) may, but is/are not required to, explain their position
regarding the allegations in writing. A written response should be delivered to the
Operations Lead before the next league event or practice regarding the acceptance of or a
rebuttal to the allegations.
f.The Operations Lead will, then take the grievance to the board of leads to decided the next reasonable course of
action.
The course of action should be related to the nature of the grievance(s)
and will also reflect the severity of the issue and may depend on the number of
grievances the person with whom the grievance is directed at has. Consequences
may include but are not limited to the following:
i. Interviewing involved parties for further information
ii. Conducting a hearing or mediation to attempt to resolve the
dispute
iii. Written or verbal acknowledgements/affirmations of league rules
and policies
iv. Disciplinary sanctions such as suspension from practice(s)and/or
league events for varying periods of time
v. Removal from positions of authority and/or responsibility
including but not limited to; team captain, co-captain or assistant
co-captain, committee chair or co-chair, and Board of Governors
vi. Expulsion from league
g. Board of Leads may also, at their discretion, address any
infraction(s)that the committee as a whole has found to be in violation of CVDG
Handbook, Code of Conduct or Bylaws without a formal grievance being filed by
an outside party.
h.The decision of the Leads will be binding for all parties involved. This includes the opinion on what is and what is
not to be considered a legitimate grievance issue.
i. In the event of disciplinary suspension or expulsion from the league,the
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Coachella Valley Derby Girls
disciplined party(s) is/are not entitled to any refund of dues and/or costs expended
on league activities.
j. The Board of Leads reserves the right to make any future amendments to this procedure.
Additional Grievance Procedure Policies
CVDG Discipline Policy is subject to change. A current copy will be kept in the "Files" section of Yahoo groups, within the
Handbook& Code of Conduct document. Please refer to this site periodically for updates and changes to this policy
Code of Conduct violations will be subject to discipline.
The violations shall be classified* into three (3) categories:
1 Minor Violations
2. Major Violations
3. Immediate Expulsion
1. Minor Violations include, but are not limited to:
• Email Violations(Posting Inappropriate Messages etc.)
• Unsportswoman-Like Behavior(Practices, Bouts, Events)
• Participating in Negative Gossip
• Negative Representation of the CVDG League
2. Major Violations include, but are not limited to:
• Any Aggressive Threatening Comments or Behavior(Including Emails)
• Physical or Emotional Harm
3.Grounds for Immediate Expulsion include, but are not limited to:
• Criminal charges related to violent crimes will be grounds for immediate suspension, with
reinstatement or revocation of skater membership pending acquittal or conviction of crime
• Threats of instances of intentional physical violence against skaters, referees, volunteers or other CVDG staff, or
spectators
• Disclosing material or information outside of the league that the Board of Leads has deemed confidential
• Embezzling league funds
• Skating as a member of CVDG while under the influence of alcohol, narcotics, or any illegal
substances or legal substances which are not prescribed to the skater
• Sexual harassment
*Classification of violations may be determined by the Board of Leads. Grounds for immediate expulsion will be
determined on a case by case basis by the Board.
Penalties and Procedures for MINOR Violations:
First Minor Violation: Verbal Warning
No less than 5 members of the Boad of Leads shall meet to discuss the reported violation. If the violation is confirmed, the
Board shall assign the task of verbal notification to the two (2) Lead teammates of the skater(s) in question. This verbal
warning will be noted in the league member's file, and will stay in the league member's file for a period of 3 months, if no
further violations are recorded. Confirmation of the verbal warning will be signed by both the league member as well as
one member of the Board of Leads
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Coachella Valley Derby Girls
Second Minor Violation: Written Warning
No less than 5 members of the Board of Le
ads shall meet to discuss the reported violation. If the violation is confirmed, the
Board shall meet with the league member to inform them of the Code of Conduct violation, and to issue the league
member a written warning. This written warning will be noted in the league members file, and will stay in the league
member's file for a period of 5 months, if no further violations are recorded. Confirmation of the written warning will be
signed by both the league member as well as one member of the Board of Leads.
Third Minor Violation: Suspension
No less than 7 members of the Board of Leads shall meet to discuss the reported violation. If the violation is confirmed, the
Board shall meet with the league member to inform them of the Code of Conduct violation, and issue the league member a
written warning and a suspension from the league and all league-related activities for a period of two weeks. This written
warning and suspension will be noted in the league members file, and will stay in the league member's file for the entire
season.
Confirmation of the written warning and suspension will be signed by both the league member as well as at least 2
members of the Board of Leads.
Subsequent Minor Violations
These will be treated in the same manner as a Third Minor Violation, up to six(6)total violations for the season. With a 7th
Minor Violation, the league member will face possible expulsion;to be determined by the Board of Leads.
Penalties and Procedures for MAJOR Violations:
First Major Violation: Suspension
No less than 7 members of the Board of Leads shall meet to discuss the reported violation. If the violation is confirmed,the
Board shall meet with the league member to inform them of the Code of Conduct violation, and issue the league member a
written warning and a suspension from the league and all league-related activities for a period of two weeks.This written
warning and suspension will be noted in the league member's file, and will stay in the league members file for the entire
season.
Confirmation of the written warning and suspension will be signed by both the league member as well as at least 2
members of the Board of Leads.
Second Major Violation: Suspension
No less than 7 members of the Board of Leads shall meet to discuss the reported violation. If the violation is confirmed, the
Board shall meet with the league member to inform them of the Code of Conduct violation, and issue the league member a
written warning and a suspension from the league and all league-related activities for a period of two months. This written
warning and suspension will be noted in the league members file,and will stay in the league member's file permanently.
Confirmation of the written warning and suspension will be signed by both the league member as well as at least 4
members of the Board of Leads.
Third Major Violation: Expulsion
No less than 7 members of the Board of Leads shall meet to discuss the reported violation. If the violation is confirmed, the
Boad shall meet with the league member to inform them of the Code of Conduct violation, and issue the league member a
written notice of expulsion from the CVDG league and all CVDG league-related activities. All league property must be
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Coachella Valley Derby Girls
returned to the league.Additionally, CVDG will not provide a recommendation for that individual, if asked,to become a
member of another roller derby league. This expulsion will be noted in the league member's file, and will stay in the league
member's file permanently. Confirmation of expulsion will be signed by both the league member and at least 7 members of
the Board of Leads.
CODE OF ETHICS:
COACHES:
I hereby pledge to provide positive support, care, and encouragement for all players (CVDG OR OTHER) participating in
roller derby by following this Coaches'Code of Ethics:
I will encourage good sportsmanship from players, fellow coaches, officials and visiting leagues at every game and practice
by demonstrating good sportsmanship.
I will place the emotional and physical well being of my players ahead of a personal desire to win.
I will treat each player as an individual.
I will do my best to provide a safe playing situation for my players. I will check players equipment and rink.
I will never argue with or complain about a referee's calls or decision.
I will do my best to organize practices that are FUN and challenging for all VCDD players&visitors.
I will teach VCDD players the Rules& Regulations or the game as stated in the WFTDA guidelines.
I will remember that in recreational sports everyone plays as much as is possible.
I will remember that I am a coach, and that the game is for the players. I will keep myself informed of sound principles of
coaching and am aware that there is always more to learn
PLAYERS:
I hereby pledge to provide positive support, care, and encouragement for everyone involved in roller derby by following this
CVDG Players' Code of Ethics:
I will encourage good sportsmanship from fellow players, coaches, officials, and visiting leagues at every game and practice
by demonstrating good sportsmanship.
I will remember that sports participation is an opportunity to learn and have FUN!
I will be on time for every practice and game that I can, and will notify my coach in advance if I cannot.
I will do my very best to listen and learn from CVDG Coaches as well as Guest Coaches.
I will do my best at every practice&game, working hard to improve my skills and to help my team.
I will never argue with or complain about a referee's calls or decision.
I will control my temper and resist the temptation to retaliate if I feel I've been wronged.
I will treat my coaches,other players,officials and spectators with respect regardless of race, gender,creed or abilities and I
will expect to be treated accordingly.
I will play by the Rules& Regulations of the game as set forth in the WFTDA Guidelines.
CVDG is my league, regardless of my team assignment. I will treat all of my league members with care and respect.
Terms and Conditions
The rules and agreements set forth by this handbook can be changed and amended at anytime and you will be
given notice prior to the change. By signing below you agree to any future changes or amendments.
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Coachella Valley Derby Girls
I have read, understand and agree to abide by the rules, code of conduct and code of ethics set forth in this handbook .
Legal Name: Signature: Date:
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Coachella Valley Derby Girls
Registration Form
*Please Print Legibly!*
Date:
Name DOB:
Cell: ( ) Mobile Carrier: Home: ( j
Email (required):
Mailing Address: Apt:
City State Zip
How did you hear about CVDG?
On a Scale of 1-5 (5 = Excellent) How well do you skate
1 2 3 4 5
What do you know about roller derby?
Why do you want to be a part of roller derby?
We need Sponsors, Equipment, Volunteers, Merchandise, Artwork, Money etc, Please list any special skills or
resources that you may be able to offer to Contribute to the league:
Tell us about YOU! What are your hobbies? What do you do in your free time? Do you have any pets? Etc...
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Coachella Valley Derby Girls
Emergency Contacts & Medical Information Sheet
*Please Print Legibly*
This form will be used in case of an emergency:
Information wil
l be provided to Medical treatment staff. All information remains confidential.
Attach a copy of Your insurance card (front and Back) and you Photo ID
OR Email copies to Operations Lead ten Matcham at jenmatcham@gmail.com
INSURANCE CARRIER:
ID#: Group#:
Policy Holder: Policy Holder DOB:
Relationship:
Name: DOB:
Address: City: Zip:
Phone: Cell: Carrier:
Emergency Contact (Required):
Name: Relationship:
Cell Phone: ( ) Home Phone: ( )
Address: City: State: Zip:
Secondary Emergency Contact:
Name: Relationship:
Cell Phone: ( ) Home Phone: ( )
Address: City: State: Zip:
Preferred Hospitals: (The following facilities are covered by my insurance)
1. 2.
Do you have Advanced Care Directives? Yes No
Medications Currently Taking (List any OTC or prescription medications and vitamins/supplements):
Food/Drug Allergies (and short explanation if necessary):
Revised 04/29/13
Coachella Valley Derby Girls
Serious Medical Conditions (seizures, fainting, diabetes, etc...)
Family History of Medical Conditions (immediate family most importantly):
Do you smoke? No Yes Quantity Per
Consume Alcohol? No Yes Quantity Per
Any Other Information we should provide doctors?
Revised 04/29/13
Coachella Valley Derby Girls
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY
("AGREEMENT")
IN CONSIDERATION of being permitted to participate in any way in ROLLER DERBY("Activity") I, for myself for personal
representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of ROLLER DERBY Activities and that I am qualified, in
good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if at any time I
believe conditions to be unsafe, I will immediately discontinue further participation in the Activity.
2. FULLY UNDERSTAND THAT: (a) ROLLER DERBY ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY,
INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS"); (b)these Risks and dangers may be caused by my
own actions or inaction's,the actions or inaction's of others participating in the Activity,the condition in which the Activity
takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISK AND SOCIAL AND
ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL
SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation or that of
the minor in the Activity.
3. HEREBY RELEASE, DISCHARGE,AND COVENANT NOT TO SUE COACHELLA VALLEY DERBY GIRLS, their respective
administrators, directors, agents,officers, members,volunteers, and employees, other participants, any sponsors,
advertisers, and, if applicable, owner and lessors of premises on which the Activity takes place, (each considered one of the
"RELEASES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED
TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT
RESCUE OPERATIONS AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a claim against any of the Releasees, I WILL INDEMNIFY,
SAVE,AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss, liability, damage,or
cost which may incur as the result of such claim. I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS,
UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING ITAND HAVE SIGNED IT FREELY AND WITHOUT
INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL
LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS
AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
Legal Name: Signature: Date:
Revised 04/29/13
Coachella Valley Derby Girls
MODEL RELEASE AGREEMENT
For valuable consideration received, I hereby grant to Coachella Valley Derby Girls, or anyone authorized by them, the
absolute and irrevocable right and permission, in respect of the photographs,video, or any other form of media, taken of
me, or in which I may be included with others,to copyright the same, in their own name or otherwise; to use, re-use,
publish, and re-publish, the same in whole or in part, individually or in matter, in any and all media now or hereafter known,
and for any purpose whatsoever; and to use my name in connection therewith if they choose.
I hereby release and discharge the Coachella Valley Derby Girls or anyone authorized by them from any and all claims and
demands arising out of or in connection with the use of the photographs/video/other media, including without limitation,
any and all claims for libel or invasion of privacy.This authorization and release shall also insure to the benefit of the heirs,
legal representatives, licensees, and assigns of Coachella Valley Derby Girls and those authorized by them, as well as the
person(s) for whom the photographs were taken.
I am of full age and have the right to contract in my own name. I have read the foregoing and fully understand the contents
thereof.This release shall be binding upon me and my heirs, legal representatives, and assigns.
Legal Name: Signature: Date:
Revised 04/29/13
Coachella Valley Derby Girls
Revised 04/29/13
EXHIBIT "E"
(CVDG Waivers)
Attached are copies of the signed Release and Waiver of Liability, Assumption of Risk and
Indemnity from CVDG members.
772567.1
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),I, for myself,my personal representatives,assigns, heirs, and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity, and that 1 am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISC DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEAs"); (b)these Risks and dangers may
be caused by my own actions or inactions, the actions or inactions of others parttcrpafa Yp he Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMEIW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily forbinjrt this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSESr` gT$, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO sanctioning organization(s), their
administrators, directors, agents, officers, memlfers, voluu&rs, and employees , Patkcipants, officials, rescue personnel,
sponsors, advertisers, owners and lesseefi of Premises on which-the Activity r& d, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIM. LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE 01t P BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESC,II OPE AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSU OF RI INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEAS _ L I 1 , SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses atto loss, age, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS HA IIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN TLAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OIL' GE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITION LEASE LABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF PORTION7 a. -AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL s `TINUE I-- E AND EFFECT.
PRINT NAME&LEAGUE NAME:
t } C ';
PARTICIPANTS SIGNATURE: h
ADDRESS:
(Street) ( ._ " =i (state) (zip)
PHONE: DATE: aT1�
PRIMARY HEALTH INSURANCE CARRIER:
WFIDAAd.RW&R_ 1117/II _ DME81807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time,in Women's Flat Track Roller Derby
("Activity"),I,for myself,my personal representatives, assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that I understand the nature of this Activity,and that 1 am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, 1 believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES;COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS I.DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE Ok'I :PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS;;AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RIM AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDI MNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attomeyfees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ'THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT 1 HAVE GIVEN UP ;SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL.RELEASE OF,ALL,LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTIONOP'THIS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE 1N:FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: jp4ni qZ—
PARTICIPANTS SIGNATURE:
ADDRESS: /1441 C93
(Street) (Gity) (State) (ZIP)
PHONE:� � L��Qc, 9 UQ 1/ DATE:� I�, r�
PRIMARY HEALTH INSURANCE CARRIER:*Ju'l r ' I VL
WFTDA Adult W&R 1117/11
DME%1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that 1 understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH,("Risks");(b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMEDBELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foresegabic at this time;and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, otheit;participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is`conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, 1N WHOLE OR PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERA3'FONS;,AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ. THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP-SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL'RELEASE OF."ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING,SHALL CONTINUE INFULLFORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: Anil e trt
PARTICIPANTS SIGNATURE:
ADDRESS2/ I30 fiv en Q /V� �1��7A 9 6 /Q—/
7
�/ (Street) (City) (State �j (Zip)
PHONE: / "r� <951 U 7 � Z DATE: (9
PRIMARY HEALTH INSURANCE CARRIER:? 1 67w C NLOI C`e, `' hr �QyahhP mp- qe',/
V
WFTDA Adua W&R 11/7/II DMEN19076/2
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in W omen's Flat Track Roller Derby
("Activity"),I,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, 1 believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH+("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions, the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES"NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and [ FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees,other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity"is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTIO14 OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WWILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss, liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT 1 AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL.RELEASE OF ALL<LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: e i✓ /ZOti AW PEAD rtits xt aSE' ,.7Fk N ELL A UAL -Y A eus
PARTICIPANTS SIGNATURE: /'
ADDRESS: 500 (-�F cTf FALL_ RD f,4i-N S1�Kt�6S ( A 92 z i, V
(Street) (City) '' (State) (ZIP)
PHONE: L`3 57'Z- `%3�„� DATE:
PRIMARY HEALTH INSURANCE CARRIER:
WF DAAdWt W&R 11n111 DMEN1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
1N CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),I,for myself,my personal representatives, assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND, DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions, the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is.conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE-READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR 'ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF:THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL
C��ONTINU
E IN FULL FORCE AND EFFECT,
PRINT NAME&LEAGUE NAME: l NV} ttQn &b(, EAsk
PARTICIPANT'S SIGNATURE:
ADDRESS: KK V% `(ftV1 r a C61, - I'(UL beae l CA- L qjj-( l
,(Street) (CRY) (State) (zip)
PHONE: �'O LJ OI DATE: i,/I 3
PRIMARY HEALTH INSURANCE CARRIER: a
WFrDAAdu1[W&R 11/7/11 DME 81807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in W omen's Flat Track Roller Derby
("Activity"), 1, for myself,my personal representatives,assigns,heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of this Activity, and that 1 am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b) these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, 1N WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND 1 FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss, liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: �4A��U � 'EOF ai� HI Qh! rEjS 1 `1d
PARTICIPANTS SIGNATURE: iY kt�--
ADDRESS:Q Cl 300 W G SYl I elgA,'o SA Aot hd L� n(,^ G -\Dwus , 9 ) 2(D S
(Street) // (G ) (State) (zip)
PHONE: 15 0 9 I Cl w DATE: 9 A I ,I
PRIMARY HEALTH INSURANCE CARRIER: � I V.x oXaS 5
WFTDA Adult W&R 11/7/I1 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that 1 understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b) these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES 1 incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND 1 FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING,SHALL CONTINUE IN FULL FORCE AND EFFECT. h
PRINT NAME& LEAGUE NAME: �LI�XD THIS l V I I
PARTICIPANTrs SIGNALT�U�R`E: `/) Q ` J�
ADDRESS:. A�� XJ Nc � 0 I D� 1OL
/f (Street) My)
(City) ` (State) (zip)
PHONE: I _L I DATE:
PRIMARY HEALTH INSURANCE CARRIER:
WFT0AAd.1t W&R 11M11 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement')
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"), I,for myself,my personal representatives,assigns,heirs, and next of kin:
1. ACKNOWLEDGE,agree, and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT 1 AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT 1F ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDIING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME a LEAGUE NAME: LGLCL1_I, ' �" "st
PARTICIPANTS SIGNATURE:
ADDRESS: �S v ��v✓i l�Grr/�G9�k l—yi �� 1� �2z ? 0 l
> (Street)! (City) (state) (zip)
PHONE:
C/ � C\1 C�7�— �� � 7 DATE:
—�--T—
PRIMARY HEALTH INSURANCE CARRIER:
weroAAd.nwaa 10111 DME HIS07672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that 1 understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, 1 believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY,INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions, the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf, makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT 1S HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CON(T-INUE IN FULL FORCE AND EFFECT,
PRINT NAME& LEAGUE NAME: �JY `ee'� � tY v �tt �{�> �Za�LChej(°� �)eykg� (0iA S
PARTICIPANT'S SIGNATURE:
ADDRESS: `I�f v�- 5 JCL c SIT I Cl/LG( � G �J I
(Street) (City) (State) (zip)
PHONE:�(rr 0 � /0 l q 2 J1 DATE: ��/j� / I
PRIMARY HEALTH INSURANCE CARRIER: I D m,,, L- +n� V-v) ' v�e�5`
�t15[Ln� e_n r
WFDAAd"D W&R 11.M 11 DMENIN7672
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that 1 understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at aqy time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b) these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES 1 incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss, liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT 1 HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL.RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: ZIAD HFI s'Wkid '
PARTICIPANTS SIGNATURE: �, / d Q /-�
ADDRESS: 5 yu(w 1 Jf � '4 J Gb l "r1 I Z ZV3
l (Street) (City) (State) (Zip)
PHONE:() L1( I57L IJ' --Tl /w DATE:4A
PRIMARY HEALTJJH INSURANCE CARRIER:
WFrDAAduDW&R linlII DMEMN7672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. 1 further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks");(b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND l FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf, makes a claim against any of the RELEASEES,I==WILL INDEMNIFY, SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ T141S AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL. RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT 1F ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE, NOTWITHSTANDING,SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME& LEAGUE NAME: / 1 's
PARTICIPANTS SIGNATURE:
�z
ADDRESS: L ate) j (ZIP)
"
(Street) (may)
PHONE: / J DATE: 5
PRIMARY HEALTH INSURANCE CARRIER: �`� l��/l �,��r✓� y
WFfDAAduIt W&R ❑nAl DME#IN7672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that 1 am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISES AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS,AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE "RELEASEES" NAMED,BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is. conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READTHIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP,SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL_RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT 1F ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING,SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: -,d+e 1-112ye a fjt
PARTICIPANTS SIGNATURE:
ADDRESS: l C "
(Street) (City) / (State) (zip)
PHONE: DATE: C f f
PRIMARY HEALTH INSURANCE CARRIER:
DMEVI80]6S
WF DAAAWIW&R IV9/11
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that 1 am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b) these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES,COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES;I WILL INDEMNIFY,SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage, or cost which may be incurred
as the result of such claim-
1 ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: co H-z,t.S VAtws vrkmm',bse IIJ(p
PARTICIPANT'S SIGNATURE:
ADDRESS: 4L2 8 "6 o M 0 Jr,Fr8t4 C'i��1rc !n1 b1&-,S W 4ti! S 922=/0
(Street) (city) (State) (Zip)
PHONE: t o q Z 3 2—too DATE: 4 • 1 1 1 3
PRIMARY HEALTH INSURANCE CARRIER:
WFrDAAdu11W&R 11M11 DME91807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"), 1,for myself,my personal representatives,assigns,heirs, and next of kin:
1. ACKNOWLEDGE,agree, and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS,AND DEATH("Risks"), (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY,SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees,loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
�LLIIJ�t V � V33L f �41 LVS
PRINT NAME 8 LEAGUE NAME:
PARTICIPANT'S SIGNATURE:
ADDRESS: -II/N(i,5 L /G) ct R Cu q✓l k C--Y`
(Street) (City) (State) (zip)
PHONED 'L7a�V —� DATE:
PRIMARY HEALTH INSURANCE CARRIER: Ms
WFTDAAdu1t W&R 11M11 DME#1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that 1 understand the nature of this Activity,and that 1 am qualified, in good health,
and in proper physical condition to participate in such Activity. 1 further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions, the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES 1 incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, 1N WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf, makes a claim against any of the RELEASEES,i WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss,liability,damage,or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT 1 AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME: 1�� / Fi'A� I HIS ueLr.+C L
PARTICIPANT'S SIGNATURE:
ADDRESS:
(Street) �j (Ctty) q (State) (Zip)
PHONE: % L� I�� CI��`2 DATE:
-- '
PRIMARY HEALTH INSURANCE CARRIER:
WFrDAAduIt W&R IVRII DMENIN07672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in Women's Flat Track Roller Derby
("Activity"),1,for myself,my personal representatives,assigns,heirs,and next of kin:
1. ACKNOWLEDGE, agree,and represent that 1 understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. 1 further agree and warrant that if, at any time, I believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b) these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity,the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c)there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES 1 incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf, makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses, attorney fees, loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME&LEAGUE NAME:
PARTICIPANTS SIGNATURE, V/
ADDRESS: ���5 t t 1 PS `� CCU G� C,�� C,o c L-Z,��-1
(Street) (City) (State) ( ip)
PHONE: �C� �C1 �1 01 [� �1 DATE:
PRIMARY HEALTH INSURANCE CARRIER: ' a
WFTDA AduD W&8 1IQ/11 DME H1807672
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way,at any time, in W omen's Flat Track Roller Derby
(`Activity"),I, for myself,my personal representatives,assigns,heirs, and next of kin:
1. ACKNOWLEDGE, agree,and represent that I understand the nature of this Activity, and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the
conditions to be unsafe, I will immediately discontinue further participation in this Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b) these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and 1 FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE,AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees; loss,liability,damage, or cost which may be incurred
as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT
FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID,THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
PRINT NAME& LEAGUE NAME: �UY , l A aA RD FH1
PARTICIPANTS SIGNATURE:
ADDRESS:
7 (Street) (CI (State) (Zip)
PHONE: /�� I1�2 /y/3 2,0 - DATE:
PRIMARY HEALTH INSURANCE CARRIER: I r GV1
DME NI807672
WFrDAAdu1t W&R 11M11
RELEASE AND WAIVER OF LIABILITY,ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")
IN CONSIDERATION of being permitted to participate this date, in any way, at any time, in Women's Flat Track Roller Derby
("Activity"), I, for myself,my personal representatives, assigns,heirs,and next of kin:
1. ACKNOWLEDGE,agree,and represent that I understand the nature of this Activity,and that I am qualified, in good health,
and in proper physical condition to participate in such Activity. t further agree and warrant that if, at any time, l believe the
conditions to be unsafe,I will immediately discontinue further participation in this Activity-
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY
INJURY, INCLUDING PERMANENT DISABILITY,PARALYSIS, AND DEATH("Risks"); (b)these Risks and dangers may
be caused by my own actions or inactions,the actions or inactions of others participating in the Activity, the conditions in which
the Activity takes place,or THE NEGLIGENCE OF THE 'RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS
or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT
AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a
result of my participation,in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their
administrators, directors, agents, officers, members, volunteers, and employees, other participants, officials, rescue personnel,
sponsors, advertisers, owners and lessees of Premises on which the Activity is conducted, (each of the forgoing shall be
considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON
MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE
RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 1, or
anyone on my behalf,makes a claim against any of the RELEASEES,I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS
EACH OF THE RELEASEES from any litigation expenses,attorney fees,loss, liability,damage, or cost which may be incurred
as the result of such claim.
1 ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT,
HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I
INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST
EXTENT ALLOWED BY LAW AND AGREE THAT 1F ANY PORTION OF THIS AGREEMENT 1S HELD TO BE
INVALID, THE BALANCE,NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT-
PRINT NAME&LEAGUE NAME: ` Sr` V � ` I�• � ���
PARTICIPANTS SIGNATURE:
ADDRESS:
(Street) (City)
PHONE: C DATE: ]
PRIMARY HEALTH INSURANCE CARRIER:
�J
WFrDAAduRW&R IIP//11 DMENISW612