Recruitment Packet 2011

Recruitment
Packet 2011
Our MIssion Statement
The Omaha Rollergirls (“ORG”) mission is to promote the stregth,
athleticism and independence of women through the sport of flattrack roller derby and to provide the skills and training necessary for
participation at a regional, national and international level. Furthermore,
the Omaha Rollergirls seek to improve the community in various ways
through their community outreach events and volunteer work.
COMMUNICATION
Our most important means of communication is online. We communicate through a Yahoo! forum.
If you do not have internet access, please make sure that you have a contact that will call you in case
of an emergency or to keep you updated on current events with the ORG. We do not have a calling
tree and all updates are available through the forum.
YAHOO! FORUMS
Bootcamp/VIP/Potential Referee Forums (open to anyone):
http://groups.yahoo.com/group/ORGCamp
Main Forum upon passing Bootcamp and League Invitiation (by invite only):
http://sports.groups.yahoo.com/group/OmahaRollerGirlsForum
SOCIAL MEDIA AND ONLINE
Web site: www.omaharollergirls.org
Facebook: www.facebook.com/Omaha.Rollergirls
Twitter: www.twitter.com/OxRxG
PRACTICES
Practices are held three to four times a week at the ORG practice space, also referred to as the
“Bunker”, which is located at 9006-I Maple St., Omaha, NE. We will notify you of any schedule
changes as soon as possible through the Yahoo! forum and by verbal announcements at practice.
The schedule for 2011 is as follows (subject to change due to coaching committee scheduling):
SUN
MON
TUES
WED
THUR
Noon - 2 pm
As needed primarily for
Charter/AAA
team scrimmages
after bouts
7 - 9 pm
Endurance
Training (all
skaters, skating
referrees)
7 - 9 pm
7 - 10 pm
7 - 9 pm
Scrimmage (all
skaters, referees,
NSOs)
2 - 4 pm
Referee Practice
9 - 10 pm
Charter Team
Practice
As needed Testing/Skills/
primarily use
Offskate
for skills clinics, Workout/Rookies
referee practices,
testing and make
up practices
9 - 10 pm
AAA Team
Practice
FRI
SAT
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REQU
ALL PARTICIPATING SKATERS MUST:
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Be a female, 18 years of age or older
Provide photo ID and proof of health/medical insurance
Read and sign the ORG liability waiver (attached)
Read the ORG By-Laws and Constitution, sign and return
the “Agreement to Comply” page (provided at the
recruitment session or beginning of bootcamp)
Understand and accept the inherent risks of participating in
roller derby
Read and understand the current Women’s Flat Track Derby Association (“WFTDA”) Rules and Regulations
SKATERS - TO REMAIN ON THE ORG ROSTER:
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Maintain minimum attendance as outlined in our bylaws (as
a general rule, that’s an average of 2 out of 3 practices per
week)
Remain current on dues (detailed below)
Meet skating skill and safety standards as determined by
the coaching staff and based upon WFTDA Minimum Skills
Requirements
Bear the expense of all personal equipment, uniforms, dues
and travel
Abide by the policies/procedures as set forth in the By-Laws
MONTHLY DUes
Dues in the amount of $35.00 per skater will be collected the 15th day of each calendar month.
Dues can be paid in monthly, 3-month and 6-month installments. If you choose to pay in 3-month
installments the cost of dues is $90 (saves $15) and 6-month installments the cost of dues is $170
(saves $40).
INSURANCE
Womens Flats Track Derby Association (“WFTDA”) is the international governing body for women’s
flat track roller derby. All league members – skaters and referees – are responsible for obtaining an
annual membership of insurance coverage with WFTDA (averaging $55.00 per skater.) The insurance
dues are required to be paid before you are allowed to participate in bootcamp and is renewed on
an annual basis in lieu of dues for that month. We strongly encourage everyone to obtain primary
insurance outside of the WFTDA insurance.
ATTENDANCE
New skaters are required to maintain a minimum of 50% attendance for two months to submit a
derby name once accepted to the league. Attendance of at least 60% is required to be considered
for placement on a team, as well as passing all skills assessments. Any skater whose attendance falls
below 30% will be dismissed from the league.
SAFETY
ALL protective gear must be worn during all skating activities. This includes knee pads, elbow pads,
wrist guards, helmets and mouth guards. Additional protective gear such as ankle support and
tailbone protectors should be taken into consideration. Skating under the influence of drugs and/or
alcohol will not be permitted at ORG practices or during bouts.
PRotective gear
required gear - What you will need to SKATE
KNEE PADS
Brands: Common brands include Triple 8, TSG, Rector, Pro-Tec, S-One and Scabs.
Please note: Rector’s come in “standard” and “fat boy”. The “fat boys” have more
padding and covers more of the knee. If you have a previous knee injury or want more
protection and support, we recommend the “fat boys” or wearing a gasket underneath
your kneepads that will keep your knee pad from slipping.
Where can I purchase: Triple 8, TSG, Rector, Pro-Tec, S-One can be found at local
skate shops or online and Scabs can be acquired by the ORG league.
Care and replacement: Air out your pads after each practice. Replace at least once a
season. Inspect for rips or signs of the padding material wearing away or breaking down.
ELBOW PADS
Brands: Common brands include Triple 8, TSG, Rector, Pro-Tec, S-One and Scabs.
Look for options that are fabric. Plastic with velcro is not enough protection.
Where can I purchase: Triple 8, TSG, Rector, Pro-Tec, S-One can be found at local
skate shops or online and Scabs can be acquired by the ORG league.
Care and replacement: Air out your pads after each practice. Replace at least once a
season. Inspect for rips or signs of the padding material wearing away or breaking down.
NOT REQUIRED
BUT A GOOD IDEA to have
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WHERE TO BUY
YOUR EQUIPMENT
WRIST GUARDS
Brands: Common brands include Rector, Pro-Tec, Triple 8 and TSG.
Where can I purchase: Online, skate shops, sporting good stores.
Care and replacement: Air out your pads after each practice. Replace at least once a
season. Inspect for rips or signs of the padding material wearing away or breaking down.
HELMET
Brands: Your helmet should be designed for multiple impacts (bicycle helmets are not).
Most skateboard helmets are appropriate. The recommended brands are Triple 8 or
S-One.
Where can I purchase: Online, skate shops, sporting good stores.
Care and replacement: If you receive a head injury replace your helmet. Depending on
the helmet you can replace the padding inside the helmet if after washing the smell does
not go away.
MOUTHGUARD
“Boil & Bite” mouthguards, such as Shock Doctor or Tap Out are pretty inexpensive.
People with smaller mouths may find a child size more comfortable. You can also contact
your dentist for a custom mouthguard. It will be more expensive but if you have braces
or have already spent a lot of money making your smile pretty, custom is the way to go.
Where can I purchase: Any sporting good store, online at tapoutmouthguard.com.
Care and replacement: Replace every 3-4 months. Brush it often with a toothbrush or
soak in mouth wash. Make sure that the mouth wash is not alcohol based as it will wear
down the plastic/silicon material quickly.
SKATES
Brands: Quad speed skates come in men’s sizes; you will need a size that is
approximately 1-2 sizes smaller than your own shoe size. When looking for a size ask to
try on someone else’s skate as the team owns a variety of sizes and styles that can help
you find the right skate. Most importantly, ask questions! Everyone has different feet and
most of the skater’s have been through the buying-and-breaking-in-process. We may be
able to save you from an expensive mistake.
For vinyl skates we recommend R3, Carreras or Boxers (range from $100-$150). When
you want to upgrade to a leather boot we recommend the Riedell 265’s (around $300).
Where can I purchase: Online, skate shops.
GASKETS - keeps knee pads
from slipping and adds an extra
layer of protection
SHIN GUARDS
OUTDOOR WHEELS - usually a
grippier wheel used for trail or
outdoor skating
BANDANAS - helps to soak up
sweat under your helmet
SHOE LACES - typically you
want 70 inches in length and a
sports driven construction
DUCT TAPE
3 IN 1 OIL - for bearings
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ONLINE
sincityskates.com
lowpriceskates.com
rollergirlskates.com
wickedskatewear.com
rudechix.com
Talk to the sponsorship director if
you plan to use one of these sites.
Many offer 10-15% discounts and
free/discounted shipping with a
league code.
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SKATE SHOPS
BBB Skate Shop
5030 Underwood, Omaha
402-933-9113
BC Boardsports
Westroads Mall
10000 California, Omaha
402-390-2398
Next Generation Secret Spot
529 N 78th St, Omaha
(south of Roberts Skatepark)
402-391-6398
7704 S 36 St, Bellevue
402-933-1301
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Typical
HOW DO YOU WIN THE GAME (A.K.A. BOUT)?
The team with the most points after two 30-minute periods
wins the game. Each period is made up of individual “jams”
lasting no longer than two minutes.
Jam Line
WHEN DOES GAME PLAY STOP?
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When a team calls a time-out, the referees need to discuss a
call and an “official time-out” is taken or when a severe injury
stops the jam.
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JAMM second
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HOW DO YOU SCORE POINTS?
The sprinting skater with a star on her helmet is the jammer.
Each team has one jammer. The jammer is the only skater who
can score points by passing blockers on the opposing team.
If jammers are not in bounds or they make illegal contact with
opposing skaters while passing, they do not score points. Also,
jammers do not score on their first pass through the pack.
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BLOCK first
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WHO ARE THE BLOCKERS?
There are four blockers from each team on the floor at one
time. Together, the eight of the blockers make a pack. Blockers
play offense by assisting their jammer at the same time play
defense and block the opposing jammer.
WHY DOES ONE GIRL HAVE A STRIPE ON HER HELMET?
The girl with the stripe is called the pivot. The pivot is a
blocker who sets the pace of the pack. She watches for the
opposing team’s jammer and calls out plays accordingly. If a
jammer passes her star helmet cover to the pivot, the pivot can
take over the jammer position.
WHAT’S A LEAD JAMMER?
The lead jammer is the first jammer to pass through
the pack legally. The lead jammer is the only person
who can call off a jam prior to the full two minutes. She
calls off the jam by repeatedly placing her hands on
her hips. The lead jammer is identified by a jammer
ref pointing to her with “L” shaped arms
while following beside her inside the track.
Sometimes there will be no lead jammer
and the jam will last the full two minutes.
LEAD
JAMMER
WHY ARE GIRLS SENT TO THE PENALTY BOX?
Girls are sent to the penalty boxes because they have
accumulated four minor penalties or committed one major
penalty. The difference between a major and a minor penalty
is whether the violation causes a “change in play” or gives the
offending team a scoring advantage. The penalty time starts
once the girl sits in the seat, so it’s essential that she get to
the penalty box quickly once assessed a penalty. The standard
time in the box is one minute, but girls can do extra time for
getting sassy with the refs.
WHAT ARE EXAMPLES OF MINOR FOULS?
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Hitting an opponent with forearms
Hitting an opponent with an elbow
Hitting an opponent in the back
Hitting an opponent when she is out of bounds
WHAT ARE EXAMPLES OF MAJOR FOULS?
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Fighting
Insubordination to a referee
Giving a malicious or dangerous illegal hit
Acting with gross unsportsmanlike conduct
See www.wftda.com for official rules and minimum skill
requirements.
FAQ’s
HOW DO I GET A DERBY NAME?
WHAT CAN I DO AHEAD OF TIME TO PREPARE?
You “earn” your derby name upon graduation of bootcamp,
confirmation that all testing has been passed and you’ve
maintained a 50% attendance for two month prior to
submission. Once you have come up with your name and
number check the National Derby Name Registry to ensure
that the name is available. Once you’ve confirmed that it is
available you will submit it to the Recruitment Director and she
will submit it to the registry. To view the registry please visit
www.twoevils.org/rollergirls/?c=3.
So you’re ready to attend boot camp but see that it’s a couple
of months away. We suggest that you begin conditioning your
body for what lies ahead by starting some of the following
activities:
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WHAT CAN I EXPECT THE FIRST PART OF BOOTCAMP?
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As outlined in the WFTDA Minimum Skills Requirements (see
attached) you will be put through drills and training during
the first five weeks of bootcamp that are geared to help you
pass the first three sections of skills - Basic Skating, Falls and
Balance/Agility.
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There will also be breakout sessions, such as “How to Care for
and Maintain your Skates”.
Upon successful completion of this section of skills you will
move on to the second part of bootcamp.
WHAT CAN I EXPECT THE SECOND PART OF
BOOTCAMP?
As outlined in the WFTDA Minimum Skills Requirements (see
attached) you will be put through drills and training during
the second five weeks of bootcamp that are geared to help
you pass the next six sections of skills - Skating with Others,
Blocking and a written Rules test.
What can
you hit
with?
•
SKATE - Order your skates and protective gear ahead
of time and get to as many open skating sessions as
possible. There is nothing better to ensure your success
as a “Fresh Meat” than having confidence on your
skates.
CONDITION - Get your core and legs stronger now. We
suggest starting with short sets of crunches, push-ups,
squats, lunges and leg lifts. Start small and build up your
sets slowly over a couple of weeks.
CARDIO - you will thank us later for this tip. Getting on
skates is good but speed walking, jogging, taking an
aerobics class or spending some time on a stationary
bike will also increase your endurance while you wait for
boot camp.
LEARN - Get on the internet and look it up! There are
many resources about derby and You Tube has a ton of
videos of derby in action. Whether it’s watching tutorials
on how to do crossovers or watching some of the best
leagues in the nation play, taking this time now to learn
will only help you once you get out on the track.
Where
can you
hit?
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OTHER
IN THE ORG
If you decide that the sport of Roller Derby is not for you because of the committment, injuries or other conflicts, please
know that you can still participate. Also, even as a skater you may have friends or a “derby widow” or spouse that would
like to help. We are always looking for supporters and we greatly appreciate any interest in the ORG. Please contact the
Recruitment Director for other opportunities within our league. So, where could you help?
ORG ARMY
These individuals will assist with bout production such as “Talk Derby” girls, merchandise sales, program sales, track set
up and much more.
NON SKATING OFFICIALS
These individuals are officials who are off skates and manage the bouts with duties such as:
Jam Timer: The Jam Timer will be responsible for starting the jam, ensuring that jams do not go longer than two
minutes and timing timeouts.
Point Trackers: tracks points for the referees.
Penalty Wrangler: takes in penalties from out side white boards and watch/listen to Inside Pack Refs for penalties.
Penalty Tracker: documents BOTH teams penalties to the official penalty sheet and relays to Large White Board
Operator how many penalties every player has accumulated.
Large White Board Operator: marks the penalties on a white board for the teams to see how many penalties each
player has.
Outside Penalty White Board: marks the penalties on a white board giving to them by Outside Pack Ref to relay
Penalty Wrangler.
Penalty Box: sets up between benches, but arranged so they are on opposite sides of own team.
REFEREES
Seven Positions are used to cover the Jammers and the Pack:
Outside Pack Check: checks for passes OOB (Out of Bounds), penalties and out of plays.
Jammer Refs: Watches the Jammers for any penalties that are made toward them or around them, tracks points.
Inside Pack Refs: Watches for inside pack penalties.
PACK IS
HERE!
WHO TO CONTACT
Coaching - Midlife Crashes, org.coaching@gmail.com
Recruitment - Nic-Rageous, org.recruiter@gmail.com
PR - Soul Crusher Sally, org.pr1@gmail.com
Sponsorship - Shaw No Fear, org.sponsorship@gmail.com
Finance - Sharon Misery, org.finance@gmail.com
Events - Daisy Mayhem, org.events1@gmail.com
Merchandise - Bruiseberry Muffin, org.merch@gmail.com
Special Events - Miss Judged, org.activities@gmail.com
Head Referee - Crash Hartless, org.referee@gmail.com
Emergency Medical Release & Liability Waiver
Participant’s Name _____________________________________________________________________
Date of Birth __________________________ Phone ________________________________________
Street Address _________________________________________________________________________
City/State/Zip Code ____________________________________________________________________
Emergency Contacts
Emergency Contact _______________________________
Home Phone __________________________________
Relationship ______________________________
Cell Phone ___________________________________
Alternate Emergency Contact _____________________________ Relationship ________________________
Home Phone __________________________________
Cell Phone ___________________________________
Allergies _________________________________________________________________________________________
Medications _____________________________________________________________________________________
Other Medical Conditions _______________________________________________________________________
Insurance Information
Primary Physician _______________________________________________________________________________
Address _____________________________________________ Phone ___________________________________
Insurance Provider ___________________________________ Policy/Group Number ____________________
Policy Holder’s Name ________________________________ Relationship to Participant _______________
Hospital Preference _____________________________________________________________________________
THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE
COMPLETED BEFORE PARTICIPANT (PLAYER/COACH/REFEREE) CAN PARTICIPATE IN
ACTIVITIES. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED
HEREIN.
In consideration of participation in any roller derby competition conducted under the auspices of
Omaha Rollergirls ("ORG"), its member unions, clubs, organizations and individuals (the
"Activity"), I, the undersigned, agree that:
1. I understand the dangers that may be caused by my own actions or inactions, the actions or
inactions of others participating in the Activity and the conditions under which the Activity is
conducted. I understand the nature of the Activity and acknowledge that I am qualified to
participate in such Activity. I further acknowledge that I am aware that the Activity will be
conducted in facilities open to the public during the 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. I acknowledge that I have a medical insurance policy in my name and that such
insurance will be my primary source of payment should medical treatment be necessary
as a result of my participation in the Activity.
3. I will not participate in any league bout or competition without first meeting the Minimum Skills
Requirements as set out by the Women's Flat Track Derby Association ("WFTDA") which is
available in its most current form on the WFTDA website (www.wftda.com).
4. I FULLY UNDERSTAND that: (a) the Activity involves risks and dangers of SERIOUS
BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS AND DEATH ("Risks");
(b) there may be other risks and social and economic losses either not known to me or not
readily foreseeable at this time; and I FULLY ACCEPT ALL SUCH RISKS AND ALL
RESPONSIBILITY FOR LOSSES, COSTS AND DAMAGES incurred as a result of my
participation in the Activity.
5. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE AND AGREE TO HOLD
HARMLESS Omaha Rollergirls, its respective administrators, members, directors, agents,
officers, volunteers and employees, local organizing committees, other participants, any
sponsors, advertisers, if applicable, owners, and lesser of premises on which the Activity takes
place (each considered one of the Releases herein) from all liability, claims, demands, losses,
or damages on account caused or alleged in whole or in part by any act or omission of the
Releases in connection with the Activity or otherwise, including rescue operations, and further
agree that if, despite this release, I or anyone on my behalf makes a claim against any of the
Releases named above, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS EACH OF THE
RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEYS FEES, LOSS LIABILITY,
DAMAGE OR COST ANY MAY INCUR AS THE RESULT OF SUCH CLAIM.
6. I agree to abide by all Women's Flat Track Derby Association ("WFTDA"), Omaha Rollergirls
("ORG"), territorial and local area union rules and regulations.
7. I affirm that I am not suspended or banned from play or participation by any club local area
union, territorial union, or national union.
8. I am aware that Omaha Rollergirls has the right to revoke my membership in the league, and
therefore my eligibility to play, coach, or otherwise participate in the event of any violation of the
aforementioned statement.
9. I understand that this document may not be altered in any manner and that any alternation
without the express written consent from the Omaha Rollergirls will cause me to be removed
from the Program.
I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT
I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY
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 THAT THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN
FULL FORCE AND EFFECT.
(Revised 07/23/10)
Participant's Signature __________________________________________________________________________
Printed Name ___________________________________________________________________________________
Date _______________________________
NOTE: ATTACH A PHOTOCOPY OF YOUR INSURANCE CARD, FRONT AND BACK, TO
EXPEDITE MEDICAL TREATMENT.
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WFTDA Insurance Claim Procedures
Definition of Claim Types:
1.
Excess Medical – An Excess Medical Claim should be filed when an injury to a plan
participant (herein referred to as injured party) occurs.
2.
General Liability – A General Liability Claim should be filed when an injury occurs to
a spectator (herein referred to as spectator) at any venue in which the League has
obtained a Certificate of Insurance.
**Whether League is filing an Excess Medical or General Liability Claim, the WFTDA Safety
Protocol MUST be followed or the claim will be denied. SAFETY PROTOCOL IS NOT A
SUGGESTION, IT IS A REQUIREMENT!**
All required Forms MUST be completed IN FULL or the claim will be denied!
Procedures for Filing an Excess Medical Claim
IMPORTANT Please Note: Participants who do not have primary policies create a huge
liability for the WFTDA group policy due to high pay-outs. Simply a handful of skaters
without primary insurance can create claims that cost more then the amount of the actual
policy. This will cause all leagues an increase in future insurance costs and deductibles,
as well as a possible future decrease in the coverage offered. It is highly recommended
that all participants have primary coverage as the WFTDA group insurance is meant to be
used as SECONDARY supplemental coverage! It is only designed to cover expenses that
are NOT covered by the injured parties’ primary policy.
1.
Within 14 days of an injury occurrence, the League Insurance Rep must turn in a
completed WFTDA Accident Report. Report should be emailed to
insurance@wftda.com. All fields MUST be completed! A step-by-step explanation
of the required fields can be found at the end of this document.
a. WFTDA Insurance will provide the Accident Report to sportsinsurance.com.
Please do not submit claims independently.
b. League Insurance Rep MUST keep copies of all forms submitted to the WFTDA.
c.
2.
The injured party should collect and keep all copies of ITEMIZED medical
bills along with copies of the Explanation of Benefits (EOB) from the primary
insurance company for submission to the claims department.
Once the injured parties’ primary coverage has paid at the maximum coverage, it is
the responsibility of the injured party to notify the WFTDA Insurance Committee when
expenses are incurred that are not covered by the primary policy or plan. The injured
party will be sent the claims forms A and B with instructions. When the paperwork is
received the injured party will work directly with sportsinsurance.com’s claims
department. Notification should be emailed to insurance@wftda.com
©2009 Women's Flat Track Derby Association (WFTDA)
***Note: for participants with Primary Coverage: Eligible covered expenses will be paid
ONLY if they are in excess of other valid and collectible insurance or medical
payment plans. If the injured party is covered by any other insurance or medical
payment plan, she must first submit claim to the primary insurance. ALL
deductibles and co-pays on injured parties’ primary plan are her/his own
responsibility.
Procedure for Filing A General Liability Claim
General Liability suits can result in the claimant requesting more than just medical
expenses. Sometimes these suits are referred to as a “Slip and Fall” suits. The parties
that can be named in these kinds of suits are: The covered League, WFTDA, the covered
venue and any other associated organizations (ie: venue management, event hosts, cohosts and sponsors). The General Liability coverage will provide the lawyers needed for
this type of claim. If a claimant can prove the host(s) did not provide a safe environment
and/or the injury was sustained by an issue that could have been prevented by the host(s),
these suites can cost thousands or even hundreds of thousands of dollars. To date there
have been zero General Liability claims to any WFTDA member leagues!
The accident report can be found in the peanut. It should be completed by the League Insurance
Rep. WFTDA Insurance Chair must be notified immediately and should be copied on all
paperwork including any paperwork submitted to the host venue, or from the host venue.
Step-by-Step Instructions to Complete the Accident Report (ALL fields must be completed!)
ID#:
I. If the General Liability Claim is for participant medical only, use the League’s Insurance
Certification Number. This can be found on the Certificate of Insurance that has your
league ONLY listed.
II. For a General Liability Claim that is for an injured spectator, use the ID# that is listed on
the Certificate of Insurance that lists the specific venue where the injury took place.
The following details what information should be completed in the fields on the Accident Form
with the corresponding number referenced:
1.
2.
3.
4.
5.
The Policy Holder is the hosting league's certificate number IF a WFTDA member
League is hosting. The Policy Holder is the visiting WFTDA league's certificate number if a
USARS league is hosting.
Address of hosting League
Visiting League name
Address of visiting League
Exact address where injury occurred. (If this is a General Liability Report, it MUST
be the address listed on the Certificate of Insurance for that Venue.)
a.
b.
c.
d.
e.
f.
All Personal information must be completed
Detailed description of the incident, injury AND treatment must be completed
MUST answer if there is a Primary Policy
MUST list who the certified on-site EMT was.
It is a beneficial practice to have witnesses. It is best if the highest official on-site
is able to sign as a witness.
The League’s Safety Coordinator MUST sign the form. By signing, the Safety
Coordinator is stating that the safety protocol requirements have been met for this
incident. The Safety Coordinator does not need to be a witness, but must confirm with
the witnesses that the safety protocol requirements were met. (The Safety
Coordinator may also be the League Official.)
©2009 Women's Flat Track Derby Association (WFTDA)
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK,
AND INDEMNITY AGREEMENT
("Agreement")

                    
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
                 

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              
            

            
                 


              
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

                
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Adult W&R
6/22/07