Full New Skater Packet ()

I.C. Bruisers
Minor Skater Registration and Parental Consent Form
Eastern Iowa Roller Derby Collective
C.R. Bruisers
Legal Name of
Child
Derby Name
Date of Birth
Home Address
Parent Email
Address(es)
Primary
Telephone
Contact
Secondary
Telephone
Contact
Additional
Phone contact
Name(s) on
Facebook (if
applicable) for
Parents’
Group
Name -
Number(s) -
Name -
Number(s) -
Name -
Number(s) -
HEALTH QUESTIONAIRE
In the event of an emergency it is important that the person in charge of the group has the
necessary information about any medical condition which could affect the treatment of your child.
All information request will be treated in strict confidence, and will not necessarily
prejudice the inclusion of your child in the activity. It is in the interests of your child that full and
accurate information be given.
Recent
For?
Date?
Relevant
Surgery? (Y/N)
Any known
allergies? (List
specific
allergies)
Is your child
undergoing treatment
by a physician? (Y/N) If
yes, please give details
I.C. Bruisers
Minor Skater Registration and Parental Consent Form
Eastern Iowa Roller Derby Collective
C.R. Bruisers
Any medical
condition
which a doctor
should know
about before
carrying out
an exam (e.g.
asthma)
Please state
any
restrictions on
emergency
medical
treatment
Family
Physician
Name
Telephone
Insurance information:
Eastern Iowa Roller Derby Collective, C.R. Bruisers, and I.C. Bruisers do not provide coverage for
personal accident, illness, loss or damage incurred by participants. Participants wishing to obtain
coverage for personal accident and Third Party liability are advised to contact an insurance
company or broker.
I understand the nature of the activity to be undertaken and consider my
child/ward
fit to take part. He/she/they does not suffer from any medical condition not stated
above. I
hereby consent to the submission of the above-named to emergency medical or
surgical treatment including the administration where necessary, of a local,
general,
Name of Parent/Guardian
Parent/Guardian Signature
!
or other anesthetic.
Date:
Waiver of Liability, Release
Assumption of Risk & Indemnity Agreement
It is the purpose of this agreement to exempt, waive and relieve releasees from liability for
personal injury, property damage, and wrongful death, including if caused by negligence,
including the negligence, if any, of releasees. “Releasees” include _____________________________________________________________________________
,
Text
(LEAGUE NAME)
hereby referred to as HOST LEAGUE, its affiliate associations, local associations, member
teams, event hosts, other participants, coaches, officials, sponsors, advertisers, and each of them,
their officers, directors, agents and employees.
For and in consideration of the undersigned participant’s registration with HOST LEAGUE, its affiliates, local associations and member teams and being allowed to participate in events and
member team activities, participant (and the parent(s) or legal guardian(s) of participant, if
applicable) waive, release and relinquish any and all claims for liability and cause(s) of action,
including for personal injury, property damage or wrongful death occurring to participant, arising
out of participation in events, member team activities, the sport of roller derby, and/or activities
incidental thereto, whenever or however they occur and for such period said activities may
continue, and by this agreement any such claims, rights, and causes of action that participant
(and participant’s parent(s) or legal guardian(s), if applicable) may have are hereby waived,
released and relinquished, and participant (and parent(s)/guardian(s), if applicable) does(do) so
on behalf of my/our and participant’s heirs, executors, administrators and assigns.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume all risks relating to roller derby and any member team activities, and understand that
roller derby and member team activities involve risks to participant’s person including bodily
injury, partial or total disability, paralysis and death, and damages which may arise therefrom
and that
I/we have full knowledge of said risks. These risks and dangers may be caused by the negligence
of the participant or the negligence of others, including the “releasees” identified below. These risks and dangers include, but are not limited to, those arising from participating with bigger,
faster and stronger participants, and these risks and dangers will increase if participant
participates in roller derby and member team activities in an age group above that which
participant would normally participate in. I/We further acknowledge that there may be risks and
dangers not known to us or not reasonably foreseeable at this time.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and
agree that all of the risks and dangers described throughout this agreement, including those
caused by the negligence of participant and/or others, are included within the waiver, release and
relinquishment described in the preceding paragraph. I/We agree to abide by and be bound under
the rules of HOST LEAGUE, including the By-Laws of the corporation and the arbitration
clause provisions, as currently published. Copies are available to HOST LEAGUE members
upon written request.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge, understand and assume the risks, if any, arising from the conditions and use of roller derby rinks/facilities and
related premises and acknowledge and understand that included within the scope of this waiver
and release is any cause of action (including any cause of action based on negligence) arising
from the performance, or failure to perform, maintenance, inspection, supervision or control of
said areas and for the failure to warn of dangerous conditions existing at said rinks, for negligent
selection of certain releasees, or negligent supervision or instruction by releasees.
If the law in any controlling jurisdiction renders any part of this agreement unenforceable, the
remainder of this agreement shall nevertheless remain enforceable to the full extent, if any,
allowed by controlling law. This agreement affects your legal rights, and you may wish to
consult an attorney concerning this agreement.
Participant (and participant’s parent(s)/guardian(s), if applicable) agree if any claim for participant’s personal injury or wrongful death is commenced against releasees, he/she shall
defend, indemnify and save harmless releasees from any and all claims or causes of action by
whomever or wherever made or presented for participant’s personal injuries, property damage or wrongful death.
Participant (and participant’s parent(s)/guardian(s), if applicable) acknowledge that they have been provided and have read the above paragraphs and have not relied upon any representations
of releasees, that they are fully advised of the potential dangers of roller derby and understand
these waivers and releases are necessary to allow amateur roller derby to exist in its present
form. Significant exclusions may apply to HOST LEAGUE’s insurance policies, which could affect any coverage. For example, there is no liability coverage for claims of one player against
another player.
________________________________________________________________ Age ________
PARTICIPANT SIGNATURE
Date Signed _______________________
_____________________________________________________________________________
PARTICIPANT NAME (PRINT)
______________________________________________ Date Signed ____________________
PARENT OR GUARDIAN SIGNATURE
(if Participant is 17 years of age or younger)
This form to be retained by local program.
www.juniorrollerderby.org
JUNIOR ROLLER DERBY ASSOCIATION
CODE OF CONDUCT
Updated 25 June 2015
1. Purpose and Goal
1.1
JRDA exists to help everyone involved, from the skaters, parents, and officials, to league volunteers and
spectators, learn and grow in a safe, fun, and supporting environment. This Code of Conduct outlines what
is expected and required of everyone who attends a JRDA practice, game, tournament, or other event in
any capacity, in order to facilitate that environment.
2. Where This Code of Conduct Applies
2.1
2.2
2.3
2.4
All JRDA games, whether sanctioned or regulation
Tournaments hosted by any JRDA league
Practices held by any JRDA league
Other derby-related events put on, held by, or sponsored by JRDA leagues or member skaters
3. Universal Behavioral Expectations
3.1
The Good
3.1.1
3.1.2
3.1.3
3.1.4
3.1.5
3.1.6
3.1.7
3.1.8
3.2
JRDA Roller Derby is a welcoming, positive, drama-free learning environment for everyone, on- and
off-skates. All participants will uphold this environment at all times.
Mutual respect and support is encouraged at all times.
Having fun and socializing - especially with other teams - is highly encouraged.
All participants will conduct themselves to develop empowerment, emphasize motivation and
enthusiasm, and celebrate each individual's abilities and individuality.
All participants will be treated with respect regardless of race, color, religion (creed), gender, gender
expression, age, national origin (ancestry), disability, marital status, sexual orientation, citizenship,
military status, or abilities.
Conduct will be sportsmanlike (sports-person-like), family-friendly, and professional at all times.
Safety is everyone’s responsibility. All participants will actively promote and model sportsmanship and
safety on and off the track.
All participants on skates must have full protective gear on at all times.
The Bad
3.2.1
3.2.2
3.2.3
3.2.4
3.2.5
3.2.6
Participants will not engage in any behavior that will endanger the health, safety, or wellbeing of any
attendees, on or off the track.
The use of undirected profanity is discouraged.
Profanity or insults directed at anyone are forbidden.
The use of illegal drugs is prohibited.
The use of alcohol, tobacco, and other legal drugs by anyone (spectators, fans, or parents) is strongly
discouraged, and forbidden except as allowed by applicable state and federal laws. Intoxication will
not be an excuse for behavior that violates any other tenant of this Code of Conduct.
The use of alcohol or any other form of chemical impairment by anyone involved with the game,
practice, or event (skaters, coaches, or officials) is forbidden while participating.
4. Spectators
4.1
4.2
Spectators are not allowed onto the track area for any reason during gameplay.
In the event there is an injury, the Head Official may make an exception to allow a parent/guardian to enter
the track.
5. Skaters
5.1
5.2
Skaters who do not pass gear check will not be able to participate until any identified issues are corrected.
If there is a dispute regarding a skater passing their gear check, only the coach may speak directly with the
Head Official to discuss the matter. The Head Official’s determination is final.
Skaters will remove themselves from any situation or drill they are not comfortable performing safely.
©2015 Junior Roller Derby Association
Page 1 of 4
www.juniorrollerderby.org
JUNIOR ROLLER DERBY ASSOCIATION
CODE OF CONDUCT
Updated 25 June 2015
5.3
5.4
5.5
5.6
5.7
Skaters will lead by example and demonstrate good sportsmanship with fellow skaters, coaches, officials,
parents, and other attendees at every game and practice.
Skaters will listen and learn from coaches and other league members.
Skaters will treat coaches, other league members, officials and fans with respect regardless of race, sex,
creed, or abilities, and will expect to be treated accordingly.
Skaters will not engage in any behavior which would endanger the health, safety, or well being of
themselves, coaches, parents, other league members, officials, or any other attendees.
Skaters will not engage in the use of profanity, verbal or physical threats, or any abuse aimed at coaches,
parents, league members, officials or any other attendees.
6. Parents
6.1
6.2
6.3
6.4
Parents will use positive tones when encouraging their children, and refrain from negativity towards or about
their child or other participants.
Parents will promote the emotional and physical well-being of all skaters on any team ahead of any personal
desire for an individual skater or team to win.
Parents will respect the officials and their authority during games and will never question, discuss, or
confront coaches or officials on the track. Issues and concerns will be brought to the team coach, and the
coach will then address concerns with the officials in the appropriate manner.
Parents will refrain from coaching their child/ren or other players, unless serving as JRDA league coach and
coaching the whole team.
7. Coaches
7.1
7.2
7.3
7.4
7.5
7.6
Coaches are responsible for parent and skater behavior at all times. If any dispute or issue arises, it is the
responsibility of the coach to notify the appropriate people, which may include the Head Official, Tournament
Director, or League JRDA Representative.
Coaches will encourage appropriate behavior among skaters, and will lead by example at all times.
Any inappropriate behavior from coaches will result in a warning/expulsion and may affect the ability to
attend other JRDA events.
Coaches will not force or pressure any league member to participate in any skating activity that they are
uncomfortable performing.
Coaches will coach in a spirit of developing empowerment, emphasize motivation and enthusiasm, and
celebrate each league member’s abilities and individuality, placing individual skater growth and development
over winning.
Coaches will encourage social influence and support from teammates with healthy attitudes towards factors
that are often targets of separation – for example, sexual orientation, race, body size/shape - and in support
of anyone who needs support for any reason.
8. Officials
8.1
Safety: Keeping all participants and spectators safe from harm is the primary responsibility of all officials.
8.1.1 Officials will check each skater for signs of injury or impairment during gear check and continuously
while on the track. Officials will not hesitate to stop play to remove an impaired or injured skater from
game play.
8.1.2 Officials will not force or pressure any skater to participate in any activity that they are uncomfortable
performing. Officials will not permit anyone else to force a skater to perform such activities.
8.1.3 Officials will immediately inform the Head Official of any physical condition, disability, injury, illness,
or any other circumstance or condition that may affect the safety and/or welfare of themselves or any
participant, or that may impact the ability of the official to fulfill his/her duties and responsibilities.
8.2 Knowledge: Officials will stay informed and execute all procedures and penalty calls to the best of their
ability based on the most current rule set. Officials will use best practices as set forth by the JRDA at all
times when available, and their own best judgment when not.
©2015 Junior Roller Derby Association
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www.juniorrollerderby.org
JUNIOR ROLLER DERBY ASSOCIATION
CODE OF CONDUCT
Updated 25 June 2015
8.3
Impartiality: Officials will remain objective and impartial at all times while wearing the official’s uniform.
Officials will conscientiously avoid even the perception of bias towards any team or league while in uniform.
8.3.1 Officials will fully disclose any and all team or league affiliations, memberships, and memberships/
affiliations of immediate family members to the Head Official/Tournament Head and place faith in their
judgment to staff games as they see fit and/or as objectively as possible.
8.3.2 Officials will execute all calls and procedures objectively and fairly.
8.3.3 Officials will not actively cheer, coach, or communicate with coaches or skaters regarding gameplay
beyond teaching and enforcing the rules.
8.3.4 To ensure effective authority in all capacities, officials who are working at any game in a multi-game
event will remain professional and unbiased during any game that they are not actively officiating.
8.4 Respect: Officials will respect those they interact with in the role of an official, and will require others to
respect that role.
8.5 Dress Code: During gameplay, all Officials must be in compliance with the JRDA Officials Dress Code. If an
Official is not currently officiating a game and wishes to cheer/coach, the Officiating uniform (SO stripes /
NSO shirt) must be removed.
9. Gameplay
9.1
9.2
9.3
All individuals participating in a game in any capacity (including spectators) are subject to the JRDA Rules,
and the authorities set forth therein.
The Head Official has the right to unilaterally remove a player or team from gameplay, or to call the game
off, for safety reasons.
If any participant’s safety is compromised at any point during gameplay, the officials will stop gameplay.
10. Tournament Play/Rankings/Sanctioned Games
10.1 JRDA reserves the right to deny game sanctioning based on rules violations, improper sanctioning
processes, or for any other reason at the discretion of the Games Department and JRDA Board of Directors.
10.2 Any disputes or disagreements regarding schedules, brackets, or seeding must be discussed with the JRDA
representative for your league prior to any event. Your league representative can contact the JRDA Games
Department and the HR Director at any time.
10.3 Tournament game schedules, bracketing, and seeding are final at the beginning of the first day of the event,
and only subject to change after this point by the Tournament/Event Director or the JRDA Board of Directors.
11. Grievance Process
11.1 Grievances may be submitted by JRDA league representatives using the grievance process found on the
JRDA Website. Parents and spectators are encouraged to speak with the coaching staff and JRDA league
representative with any issues or complaints.
11.2 JRDA will not review calls from a game; all rulings on the track are final once the official final score is
posted.
11.3 JRDA will not handle disputes between leagues unless there is concrete evidence of violation of this code of
conduct.
12. Consequences
12.1 Penalties
12.1.1 Violations of this Code of Conduct during gameplay may be penalized as Misconduct under the JRDA
rules.
12.1.2 Penalties assessed to non-skating participants will be served by the team captain as set forth in the
rules.
12.1.3 Violations of this code of conduct which occur outside of an officiated game will be deferred to the
league rep and coaches for disciplinary action at their discretion.
©2015 Junior Roller Derby Association
Page 3 of 4
www.juniorrollerderby.org
JUNIOR ROLLER DERBY ASSOCIATION
CODE OF CONDUCT
Updated 25 June 2015
12.2 Expulsion / Suspension
12.2.1 For extreme or repeated violations, the offending participant(s) may be asked to leave the venue.
Only JRDA Directors, Tournament Directors, and Head Officials may make the decision to have a
participant ejected from the facility.
12.2.2 If the offending person does not leave voluntarily, venue security or the local police may be asked
to remove them. Gameplay will not continue until the offending participant has left the premises.
Extended delay due to refusal to leave (20 minutes or more) will result in the game ending
immediately.
12.2.3 Expulsions will be reported to and reviewed by the JRDA Board of Directors. If appropriate, the Board
may suspend the expelled person, prohibiting that person from attending future JRDA events until a
specified date.
12.3 Officials
12.3.1 Violations of this Code of Conduct by any official, skating or non-skating, will be reported to the JRDA
Officials Review Board, and may be penalized by suspension from working any JRDA game for a
period of time (up to and including a lifetime ban) at the sole discretion of the Review Board.
13. Acknowledgement and Signature
13.1 By signing below, I understand that it is my primary responsibility to promote sportsmanship and safety on
the track, and I agree to place safety over and above any other consideration. I knowingly acknowledge
all expectations of this Code of Conduct, and promise to adhere to the guidelines set forth by the JRDA
and its participating leagues. I understand violation of this Code of Conduct may result in ejection from the
facility, and it may jeopardize my presence at future JRDA events. I have read and agree to abide by all
expectations set forth in the JRDA Code of Conduct.
Legal Name
Derby Name
©2015 Junior Roller Derby Association
Date
Page 4 of 4
JUNIOR ROLLER DERBY ASSOCIATION
MEDICAL RELEASE
PARENTAL AUTHORIZATION / MEDICAL RELEASE
I, parent or legal guardian, of (league members name)
hereby give
authorization for participation in any and all Junior Roller Derby Association League 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 parent nor legal guardian is 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 the JRDA and any Junior League and its agents, assigns,
representatives, officers 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 HEALTH REGISTRATION FORM AND
PARENTAL AUTHORIZATION / MEDICAL RELEASE. I VERIFY THAT I HAVE
COMPLETED THIS FORM AND THAT THE INFORMATION PROVIDED IS TRUE
AND CORRECT. I FURTHER AGREE TO ABIDE BY THE RULES/GUIDELINES
SET FORTH BY THE JUNIOR ROLLER DERBY ASSOCIATION AND MY
REGIONAL JUNIOR ROLLER DERBY LEAGUE.
Signature of Parent / Legal Guardian :
Date:
Printed Name of Parent / Legal Guardian :
Printed Name of League Member (Legal Name):
Relationship to League Member:
* With written documentation of incident kept on file by local JRDA representative.
PLEASE LIST BELOW ANY MEDICAL INFORMATION OR CONDITION WHICH MAY BE RELEVANT TO THE
CARE AND TREATMENT (EMERGENCY OR OTHERWISE) OF THE CHILD.
© 2010 Junior Roller Derby Association (JRDA)
This agreement is modified from
the WFTDA Photographer Credentials http://Wftda.com/media/wftda-photo- credential-guidelines
I.C. Bruisers Photographer Agreement
OVERVIEW: The I.C. Bruisers may issue a limited number of photo credentials for I.C. Bruisers Events at its sole discretion. The I.C. Bruisers will
select the photographers it believes are best positioned to provide coverage of their Events. This photo credentials agreement has been established to
provide you with an understanding of the rights and restrictions associated with I.C. Bruisers photo credentials.
CRITERIA FOR PHOTO CREDENTIALS Preference is given to photographers with “professional grade” equipment and significant experience
shooting roller derby bouts. The I.C. Bruisers give preference to photographers who are: a) affiliated with a competing league or team (i.e. team
photographer); b) regarded as a highly-qualified photographer within the roller derby community; c) affiliated with a non-competing league or team; d)
indirectly affiliated with a league (competing or non-competing); e) on assignment for a major media outlet (for example, wire services, networks, cable,
etc.) f) not affiliated with any league and interested in shooting for personal projects.
CREDENTIAL USAGE Photo credentials provide access to photography areas at the venue, subject to space and other limitations. Locker rooms and
backstage areas are off-limits to all photographers. Your photo credential badge must be worn at all times during the Event, and you will be subject to the
direction and/or supervision of the I.C. Bruisers and its designated representatives. Your photo credentials badge is not transferable; you may not give or
loan your photo credentials badge to another person for any reason. Any misuse of the photo credentials badge will result in the loss of the photo
credentials for the current Event and any future I.C. Bruisers events. Photo credentials do not assure free admission to the Event. The I.C. Bruisers may
restrict the use of any equipment at its sole discretion.
PROPRIETARY RIGHTS AND RESTRICTIONS You may not use, distribute, exhibit, reproduce, adapt, display, or publish any audio or visual
accounts of the Event(s), other than in the manner described below. Nothing in this photo credentials agreement authorizes or allows you to violate any
trademark, copyright, or other proprietary right of the JRDA, the I.C. Bruisers, the leagues, the teams, and/or the skaters.
EVENT PHOTOS If you have been issued I.C. Bruisers Event photo credentials, you have a limited, non-exclusive, and non-transferable license to take
and use photographs of the Event as long as such use does not imply an endorsement or sponsorship relationship between a third party and the I.C.
Bruisers, the JRDA, the leagues, teams, and/or skaters. · Since you will be photographing minor please avoid using children’s names (first name or
surname) in photograph captions. If the child is named, avoid using his or her photograph. If the photograph is used, avoid naming the child. · The photos
you take at an Event are your property. The I.C. Bruisers claim no right to use those photographs without your prior consent. The I.C. Bruisers have a
right to view the photos taken at an Event and may request a license agreement with you for use of a photo. If you have been given free admission to the
Event the I.C. Bruisers request a small number of edited photos be made available for use on the team website, for bout recaps, and on the teams social
media accounts. Guidelines for submission of these photos will be made available at the Event. Terms of the usage agreement are at the discretion of the
photographer and/or media organization. · You understand that any commercial sale of images from the Event will require model releases from any
identifiable person in the image or their guardian. You are responsible for obtaining the proper releases. · You agree not to post bout or skater
photographs that are not in the spirit of the I.C. Bruisers' values. This includes, but is not limited to, posting bout images to websites that rely heavily on
nudity, sexual content, violence, obscenity, and/or websites that advocate illegal behavior or discrimination based on race, gender, and/or sexual
orientation. · You will make every effort to avoid obstructing the view or impacting the safety of any fan, skater, official, or other attendee of the Event. ·
The ability to shoot on the track is completely at the discretion of the I.C. Bruisers. You acknowledge that the photo credential does not guarantee a track
floor shooting position. Due to space constraints, you may be assigned to alternate positions. An I.C. Bruisers liaison may provide you with location
assignments and restrictions specific to the Event and venue. If you are allowed to shoot from designated photo boxes on the track, you may only
enter/exit these areas between jams, at half-time, and during official time outs. Access to the Center Track position, if it made available, is given at the
discretion of the Head Referee and Media Coordinator prior to the event. If asked by security or officials to vacate any designated area, please do so
promptly.
ASSUMPTION OF RISK AND RELEASE You assume all risk and danger incidental to the sport of roller derby, as well as any risk or danger
reasonably foreseeable while on the grounds of the venue, and you release the I.C. Bruisers, its employees, members, directors, officers, sanctioned
tournament and host sites, title sponsors, participating skaters, volunteers, assigns, and all agents thereof from any and all liabilities resulting from injuries
or personal property loss occurring before, during or after actual play, or while otherwise at the Event venue or any associated I.C. Bruisers events.
USE OF IMAGE/LIKENESS In the event that your name or likeness is included in any broadcast, telecast, photograph, film, video, or other media taken
in connection with the Events, you grant the I.C. Bruisers a non-exclusive, transferable, perpetual right and royalty-free license to use (and to sub-license
the use of) your name and likeness in any media worldwide, whether now known or hereafter devised.
INDEMNIFICATION You jointly and severally indemnify, defend, and hold the I.C. Bruisers (and its officers, directors, and representatives) harmless
from and against any and all claims, actions, damages, liabilities, costs or expenses (including reasonable attorneys’ fees and costs of suit/arbitration)
arising out of or in connection with any act or omission by you, including, without limitation, your breach of any term of this agreement. With respect to
any claim that might give rise to your liability as an indemnitor, the I.C. Bruisers will (a) have the right to fully participate in the litigation of such claim
with counsel selected by you or your organization, and approved by the I.C. Bruisers, at no expense to the I.C. Bruisers; and (b) not be obligated, without
its consent, to participate in any settlement of such claim.
AGREEMENT You must agree to these terms upon submission of your request for photo credentials for the I.C. Bruisers Events. Submission of your
request and/or acceptance and use of the tournament photo credentials badge constitutes your agreement to abide by the terms and conditions contained
herein. Failure to abide by the terms and conditions will result in loss of your photo credentials for the current Event and future I.C. Bruisers events.
Name:_________________________________________________________
Date:____________________________________________________________
Signature:______________________________________________________
___________________________________________________
Badge Number:
Emergency Contact:
Name
__________________________________________________________
Contact Phone
__________________________________________________________
Other
__________________________________________________________