GROUP MEDICARE ENROLLMENT MANUAL GROUP MEDICARE ENROLLMENT …
OJRD Enrollment & Information Form...
Transcript of OJRD Enrollment & Information Form...
OMAHA JUNIOR ROLLER DERBY ENROLLMENT & INFORMATION PACKET
The Omaha Junior Roller Derby league is a junior flat track derby program, open to girls and boys ages 8-‐17, representing the future of roller derby. The mission of the Omaha Junior Roller Derby league is to establish a program that will help develop character, confidence, and leadership and provide a positive social interaction in youths through sports. The Omaha Roller Derby intends to nurture and develop both skilled athletes and those who have not yet realized the champion inside of them.
SKATER/MEMBER CONTACT FORM
CONTACT INFORMATION:
Name: ___________________________ _____ Age: ______ Birthdate (MM/DD/YYYY):____________________
Street: _______________________ Suite/Apt:______ City: ____________ State: _____ Zip: _________
Home Phone: _________________ Cell Phone: ______________ E-‐mail: _____________________________
School: ________________________ Grade: ______ Skater Derby Name & Number: _____________________
PRIMARY PARENT / GUARDIAN CONTACT INFORMATION:
Name: ___________________________________ Relationship: ____________________________
Address (if different from skaters – if same, leave blank):
Street: _______________________ Suite/Apt:______ City: ____________ State: _____ Zip: _________
Home Phone: _________________ Cell Phone: ______________ E-‐mail: _____________________________
SECONDARY PARENT/GUARDIAN CONTACT INFORMATION (IF DESIRED):
Name: ___________________________________ Relationship: ____________________________
Address (if different from skaters – if same, leave blank):
Street: _______________________ Suite/Apt:______ City: ____________ State: _____ Zip: _________
Home Phone: _________________ Cell Phone: ______________ E-‐mail: _____________________________
HEALTH REGISTRATION
Name: ____________________ _____ Age: ______ Birthdate (MM/DD/YYYY):____________________
Family Physician: ______________________________ Phone: ______________________________
Hospital Preference: ___________________________ Primary Insurance Carrier: ______________________________
*Please attach a copy of the Primary Insurance Card (Front and Back)
EMERGENCY CONTACT INFORMATION:
Primary Emergency Contact: ___________________________ Relationship: ___________________________
Primary Number: ___________________________ Alt Number: ___________________________
Secondary Emergency Contact: __________________________ Relationship: ___________________________
Primary Number: ___________________________ Alt Number: ___________________________
DOES YOUR CHILD HAVE OR HAS HAD ANY OF THE FOLLOWING CONDITIONS? o Yes o No ADD / ADHD o Yes o No DIABETES o Yes o No ANAPHYLACTIC ALLERGY o Yes o No EMOTIONAL CONCERNS o Yes o No ANEMIA o Yes o No EPILEPSY SEIZURES o Yes o No ASTHMA (mild, moderate, severe) o Yes o No HEARING PROBLEMS
o Yes o No BLADDER PROBLEMS o Yes o No HEART PROBLEMS o Yes o No BOWEL PROBLEMS o Yes o No VISION PROBLEMS o Yes o No DENTAL PROBLEMS o Yes o No RECENT SURGERIES o Yes o No DEPRESSION OR ANXIETY o Yes o No OTHER
Answered YES to any of the above, please explain the condition. __________________________________________________________________________________________________ Answered YES to the above, has your child visited the ER/hospital for this condition? Please explain. __________________________________________________________________________________________________ Does your child take medication of any kind? If YES, Please explain. __________________________________________________________________________________________________ PARENT OR GUARDIAN AUTHORIZATION: In case of emergency, if myself or the family physician cannot be reached, I hereby authorize my child to be treated by certified emergency personnel (e.g. EMT, First Responder, ER Physician). Signature of Parent/Legal Guardian: ________________________________ Date: ___________________
Warning: Protective equipment cannot prevent all injuries a skater might receive while participating in roller derby. The Omaha Junior Roller Derby do not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual or religious preference.
PARENTAL AUTHORIZATION/MEDICAL RELEASE I, parent or legal guardian, of ____________________________ (Skater’s Legal Name) hereby give authorization for participation in any and all Omaha Junior Roller Derby activities. I hereby grant permission to managing personnel and league representatives to authorize and obtain medical care from any licensed physician, hospital or medical clinic, should the skater become ill or injured while participating in league activities when neither a parent nor legal guardian are present to grant authorization for immediate treatment. I assume all risks and hazards incidental to such participation, including transportation to and from league activities, and do hereby waive, release, indemnify and agree to hold harmless Omaha Junior Roller Derby, Omaha Rollergirls, and it’s agency, assignees, representatives, officers and employees from any and all claims arising out of the skater’s participation in any and all league activities. I HAVE READ AND UNDERSTAND THE ABOVE REGISTRATION FORM AND PARENTAL AUTHORIZATION / MEDICAL RELEASE. I VERIFY THAT I HAVE COMPLETED THIS FORM AND THAT THE INFORMATION I PROVIDED IS TRUE AND CORRECT. I FURTHER AGREE TO ABIDE BY THE RULES/GUIDELINES SET FORTH BY THE OMAHA JUNIOR ROLLER DERBY LEAGUE. Signature of Parent/Legal Guardian: ________________________________________ Date: ___________________
SKATERS CODE OF CONDUCT
BY SIGNING BELOW I AGREE THAT:
1. I will lead by example and encourage good sportsmanship from fellow skaters, coaches, officials and parents at every game and practice by demonstrating good sportsmanship.
2. I will attend every practice and game that I can, and will notify my coach in a timely manner if I cannot. I will be on time for practices and games.
3. I will do my best to listen and learn from my coaches.
4. I will treat my coaches, other skaters, officials and fans with respect regardless of race, sex, creed or abilities, and I will expect to be treated accordingly.
5. I will do my best at school and treat my parents with respect.
6. I deserve to have fun during my sports experience and will alert parents or coaches if it stops being fun.
7. I deserve to play in an environment that is safe, free of drugs, tobacco and alcohol and will refrain from their use at all events.
8. I will remember that Roller Derby is an opportunity to learn and have fun.
9. I will learn the rules of the game of flat track derby from the WFTDA rules.
10. I will not engage in unsportsmanlike conduct with any coach, parent, skater, official or any other attendee.
11. I will not engage in any behavior which would endanger the health, safety or well-‐being of a coach, parent, skater, official or any other attendee.
12. I will not engage in the use of profanity while attending or participating in events.
13. I will not engage in verbal or physical threats or abuse aimed at any coach, parent, skater, official or any other attendee. I will not initiate a fight or scuffle with any coach, parent, skater, official or any other attendee.
14. I will keep the practice areas clean and in as good or better shape than when I found them.
15. I will ensure that I am properly dressed for practice with a top that covers my mid-‐section and is not low-‐cut, shorts will ensure full coverage.
I also agree that if I fail to abide by the code of conduct, I will be subject to disciplinary action that could include but is not limited to the following: • Verbal/Written warning by official, coach and/or head of league organization -‐ documentation of incident signed by skater will be kept on file by the Omaha Junior Roller Derby • Player game/practice suspension • Player season suspension
Signature of Skater: ________________________________________ Date: ___________________
PARENTS CODE OF CONDUCT
BY SIGNING BELOW I AGREE THAT:
1. I will not force my child to participate in the Omaha Junior Roller Derby league.
2. I will remember that children participate to have fun and that the game is for the skaters, not the adults involved.
3. I will inform the coach of any physical disability or ailment that may affect the safety of my child or the safety of others.
4. I will learn the rules of the game of flat track derby and the policies of the league.
5. I (and my guests) will be a positive role model for my child and encourage sportsmanship by showing respect and courtesy, and by demonstrating positive support for all parents, coaches, officials and spectators at every game, practice and scrimmage.
6. I (and my guests) will not engage in any kind of unsportsmanlike conduct with any official, coach, skater or parent such as booing and taunting; refusing to shake hands; or using profane language or gestures.
7. I will not encourage any behaviors or practices that would endanger the health and well-‐being of the skaters.
8. I will teach my child to play by the rules and to resolve conflicts without resorting to hostility or violence.
9. I will demand that my child treat other players, coaches, officials and spectators with respect regardless of race, creed, color, sex or ability.
10. I will teach my child that doing one’s best is more important than winning, so that my child will never feel defeated by the outcome of a game or by their performance.
11. I will praise my child for competing fairly and trying hard, and make my child feel like a winner every time.
12. I will never ridicule or yell at my child or other participants for making a mistake or losing a competition.
13. I will emphasize skill development and practices and how they benefit my child over winning. I will also deemphasize competition in the lower age groups.
14. I will promote the emotional and physical well-‐being of the skaters ahead of any personal desire I may have for my child to win.
15. I will respect the officials and their authority during games.
16. I will demand a safe sports environment for my child that is free from drugs, tobacco and alcohol.
17. I will refrain from coaching my child or other players during games and practices, unless I am one of the official coaches for the Omaha Junior Roller Derby league.
18. I will ensure that my child is appropriately dressed upon arrival at practice.
I also agree that if I fail to abide by the aforementioned rules and guidelines, I will be subject to disciplinary action that could include, but is not limited to the following (with written documentation of incident kept on file):
(A) Verbal warning by official, coach, and/or head of the league organization (B) Parental game suspension (C) Parental season dismissal
Signature of Parent/Legal Guardian: ________________________________________ Date: ___________________
FREQUENTLY ASKED QUESTIONS
WHY ROLLER DERBY? Roller derby teaches teamwork, commitment and respect for others. It also breeds self-‐confidence and self-‐esteem in the skaters. Roller derby is a very inclusive sport; there is a place for all different sizes and shapes, as well as all levels of skill and athleticism.
HOW OLD DO I HAVE TO BE? Skaters should be 8 years old on or before their first week of practice. Once skaters are 18 years old they are then be eligible for the adult leagues – Omaha Rollergirls and the Big O Roller Bros.
DO YOU ALLOW BOYS TO SKATE TOO? Roller derby is an inclusive sport, and as such, the junior league is coed and open to both boys and girls. Boys and girls practice, scrimmage, and play as a team with one another. Above all else, the coaches ensure the skaters safety, so if there is ever a skater who simply is too big, regardless of gender, they may not be able to participate fully in the league.
WHAT IF I AM REALLY LITTLE OR REALLY BIG? There is a place with in roller derby for all types of skaters. The non-‐competitive team is broken into two groups – “Lils” and “Bigs” and is based on a combination of factors: age, physical size and skill level. Skaters are assessed by the Coaches as well as take into consideration the skater’s and parents’ personal comfort to determine which category is most appropriate. As mentioned, if there is a skater that appears to be unsafe to their teammates because their physical size, they may not be able to participate fully in the league.
HOW MUCH WILL IT COST? The primary expenses will be for purchase of equipment and enrollment fees. Enrollment fees are $100 for each non-‐competitive session and $150 for the competitive session, and are due at the first practice of the session. Enrollment fees include training, USARS insurance, and a uniform. All skaters are required to have personal primary insurance, and must also obtain secondary insurance through USA Roller Sports (USARS). This insurance is required and renewed on an annual basis, and the cost is included in the enrollment fees. The first time you enroll, you are required to have a copy of your child’s birth certificate.
WHAT IS THE DIFFFERENCE BETWEEN COMPETITIVE AND NON-‐COMPETITIVE SESSIONS? OJRD is broken into two teams – the non-‐competitive and competitive team. All skaters must start with the non-‐competitive team and will be selected by Coaches to join the competitive team. Non-‐competitive sessions run for 9 weeks twice a year, and the competitive session runs for 3 months once a year between the non-‐competitive sessions. The non-‐competitive team focuses on skating skills and basic strategy. Following tryouts all skaters will be drafted onto a team for that session. At the end of each session we will have a round robin tournament for the teams to compete. The competitive team is open to skaters 12 and up and invited by the Coaches to join. There is no differentiating between Bigs and Lils, it is only one group. It is a much larger time and financial commitment as there is travel involved. Travel expenses for games against other junior leagues across the country will ultimately be up to the family, however, we may do fundraising throughout the year to help minimize the costs.
WHAT EQUIPMENT DO I NEED AND WHERE DO I GET IT? Required equipment is listed on the page titled “Protective Gear”. We highly recommend attending one of our informational meetings which are held prior to the start of each session so that you can try on the gear to ensure that it fits properly. You can also order all of the equipment at that time for a discounted rate that we have established with distributors. If you cannot make one of our informational meetings, you will need to obtain this gear on your own. There are a few local stores and websites suggested below in the “Protective Gear” section as well.
HOW MUCH TIME IS INVOLVED? Practices are twice a week and currently held on Tuesdays from 6pm – 8pm and Saturdays from 10am – 1pm. Saturday practices are broken into “Bigs” only and “Lils” only practices, which are then held from 10am – 11:30am or 11:30am – 1pm. There may also be the opportunity to appear during half times for the Omaha Rollergirls home bouts or other public appearances.
FREQUENTLY ASKED QUESTIONS (CONTINUED)
GREAT! I CAN MAKE THE TIME AND FINANCIAL COMMITMENT – NOW HOW DO I JOIN!? Before every session we will hold Informational Meetings which are optional but highly recommended. At these meetings we will go over details of what is required, you will get to meet some of the coaches, and skaters can try on and order their gear. The next step is to attend the two week tryouts which are required to be accepted into the league. Tryouts will be held a few weeks before the session starts and is required for all new skaters. These tryouts will only be for new recruits and held during the same time as practice – 6pm-‐8pm on Tuesdays and 10am-‐12pm on Saturdays. During the tryouts, the Omaha Junior Roller Derby coaches will teach new skaters one-‐on-‐one how to have good skating stance, fall safely, and perform stops. If you can complete these skills competently as assessed by the Coaches, you will be able to join us for practice!
WHAT CAN I DO UNTIL I TRY OUT? If you are unsure of your skating abilities, do everything you can to start skating now! Attend as many open skates that you can at your local roller rink and get your “skate legs” under you. Both of the local skating rinks (SkateDaze, Millard & Skate City, Bellevue) have skate lessons which we highly recommend attending before tryouts. Check their websites for more info. If you already know how to skate, we still recommend getting to the skating rink and working on your skills.
WHAT QUALIFICATIONS DO THE COACHES HOLD? The majority of our coaches are currently full time athletes with the Omaha Rollergirls. They are required to have passed a Federal background check through the FBI and also get certified in First Aid and CPR/AED through the American Red Cross. Furthermore, all coaches will adhere to the same requirements listed in the Parent & Skaters Code of Conduct. Above all else, Coaches look to ensure each child’s safety in every drill and activity.
IS ROLLER DERBY A FULL CONTACT SPORT? Adult roller derby is full contact, but not all of junior roller derby is. Depending on the skill level and junior roller derby begins with understanding the principles of positional blocking, which means positioning your body in front of another skater to stop or slow them down. As skaters progress additional contact is learned, but we promote only safe, controlled contact.
WHAT ARE THE CHANCES OF MY CHILD GETTING HURT? There’s no doubt that roller derby can be dangerous but so can cheerleading. Roller derby is a contact sport and there are injuries, but with proper equipment and training we can minimize the dangers. Following the guidelines in the Code of Conduct as well as helping ensure your child’s safety gear is properly maintained and replaced will also help prevent injuries.
AS A PARENT, WHAT CAN I DO TO HELP? Parents are more than welcome and encouraged to get involved and volunteer for the league. Many of the parents often help at practice to keep the facility clean or help keep other parents informed. Others take pictures at events or volunteer at the Omaha Rollergirls games. We are entirely volunteer ran, so any way you are able to help will be a benefit to the league’s success!
IS THERE ANYTHING ELSE I SHOULD KNOW? Junior roller derby in the United States is still in its infancy. There is no governing body currently which dictates what a league’s skater characteristics should look like. When looking for opponents, we may play other leagues which do not have the same age range as what we have and therefore your child may not be able to play during a game. Furthermore, to make things difficult, there are also very few Junior derby leagues nearby. The sport is quickly evolving and more are popping up in the region, but your patience in the development of Junior roller derby is imperative to our growth.
PROTECTIVE GEAR
REQUIRED GEAR -‐ WHAT YOU WILL NEED TO SKATE KNEE PADS Common brands include Triple 8, TSG, Rector, Pro-‐Tec, 187 Killer and Scabs. Once your child gets into the adult sizing, you will want to find those which are used in street skateboarding; preferably those that have a flat surface for “drop in” skating. Must have a hard plastic cap for protection. ELBOW PADS Common brands include Triple 8, TSG, Rector, and Pro-‐Tec. Look for options that are made from nylon and must have a hard plastic cap. WRIST GUARDS Common brands include Rector, Pro-‐Tec, Triple 8 and TSG. Look for options that are made from nylon and must have a hard plastic guard. HELMET Common brands are Pro-‐Tec, Triple 8 and TSG. Your helmet should be designed for multiple impacts and MUST have a minimum safety certification of CPSC. Most skateboard and bicycle helmets are rated this way and will have a sticker noting the safety certification. Do not assume a helmet has this safety rating if you cannot find the sticker – many are not rated. MOUTHGUARD “Boil & Bite” mouthguards, such as Shock Doctor are a well-‐respected brand, but there are also many off brands that work well too. There are many adults with smaller mouths that find a kid’s size more comfortable. You can also contact your dentist for a custom mouthguard. SKATES Quad speed skates come in men’s sizes; for females, you will need a size that is approx. 1 to 2 sizes smaller than your own shoe size. When looking for a size we recommend you get sized by a Riedell representative – both local skate rinks will be able to do this. If you are unable to do that, trying on other skates from league members can help you find the right skate size. Be sure that they fit correctly. We recognize this is the most expensive part of roller derby, but a bad fit can lead to blisters, painful skating and poor technique. Extra socks can help with half sizes if they are too big, but make sure that once their toes hit the end of the boot, they are going to need new skates that will fit. For the majority of our skaters and the ever-‐growing kids feet, we recommend vinyl skates such as R3’s, Diablo or Dash (range from $100-‐$150). When you want to upgrade to a leather boot we recommend waiting until the child’s feet have completely stopped growing and inquire with a Coach for details. CARE AND REPLACEMENT Pads & Helmets: Air out your pads after each practice. Inspect nylon cloth and padding for rips or signs of the padding material wearing away or breaking down. Inspect plastic caps for breaks. Inspect straps to ensure they are not coming lose and remain tight. Mouthguard: Soak in mouth wash or in antibacterial cleanser such as Efferdent overnight. Brush it often with a toothbrush. Make sure that the mouthguard is not chewed through and still fits securely in your child’s mouth and does not slip around.
NOT REQUIRED BUT A GOOD IDEA TO
HAVE • WATER BOTTLE – with
name in permanent marker • BANDANAS -‐ helps to soak
up sweat under your helmet and keep helmet tight
• SHOE LACES -‐ typically you want 70 inches in length and a sports driven construction
• DUCT TAPE -‐ keeping too long of straps down
• BEARING CLEANING MATERIALS o 3 in 1 all-‐purpose oil o Mineral Spirits o Bones Bearing
Cleaning Kit • GASKETS -‐ keeps knee pads
from slipping and adds an extra layer of protection
• TAIL BONE PROTECTOR / AZZPADZ -‐ for new skaters who tend to fall backwards, this will protect your tailbone which is a common derby injury
• OUTDOOR WHEELS -‐ usually a grippier wheel used for trail or outdoor skating
WHERE TO BUY YOUR EQUIPMENT
OMAHA ROLLERGIRLS GEAR ORDERS – are completed on a monthly basis so planning ahead is REQUIRED. We have negotiated great prices with national dealers to get you the most cost savings. We pass that benefit on to you and make no money in the process. ONLINE • derby4all.com • sincityskates.com • wickedskatewear.com
LOCAL SKATE SHOPS • BC Boardsports
Westroads Mall • BBB Skate Shop