User account

All user applications are for PARTICIPATING LEAGUE MEMBERS ONLY and will be reviewed by the A2D2 administration staff before appropriate permissions are granted according to membership status. Please be patient during this process :)

Account information

Username: *

Spaces are allowed; punctuation is not allowed except for periods, hyphens, and underscores.

E-mail address: *

A valid e-mail address. All e-mails from the system will be sent to this address. The e-mail address is not made public and will only be used if you wish to receive a new password or wish to receive certain news or notifications by e-mail.

1 Public Bio

Real Name: *

Please use real name, only League Members may view this and it will not be visible to the general public

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Derby Name: *

Homepage:

Bio:

Tell us a little about yourself....

Occupation:

Turn Ons:

Turn Offs:

Favorite Song:

Favorite Celebrity:

Favorite Food:

Favorite Part of Derby:

Weapon of Choice:

Family:

2 Membership Record

Classification: *

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First Name: *

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Last Name: *

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Phone No.: *

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Date of Birth: *

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Address: *

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City: *

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ZIP Code: *

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Email Address: *

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Primary Phone: *

Phone number we are most likely to be able to reach you at, home, cell, or whatever:

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Other Phone Numbers:

Any other phone numbers we may be able to contact you at.

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Employer Name:

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Employer Phone#:

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Best Way to Contact You: *

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Emergency Contacts

Contact 1 Name: *

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Contact 1 Primary Phone: *

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Contact 1 Secondary Phone:

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Contact 1 Relationship to You: *

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Contact 1 Address: *

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Contact 2 Name:

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Contact 2 Primary Phone:

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Contact 2 Secondary Phone:

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Contact 2 Relationship to You:

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Contact 2 Address:

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Contact 3 Name:

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Contact 3 Primary Phone:

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Contact 3 Secondary Phone:

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Contact 3 Relationship to You:

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Contact 3 Address:

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Emergency Other

Primary Care Physician:

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Primary Care Physician's Phone No.:

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Preferred Hospital for Emergency Care:

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Injuries, Allergies, Surgeries or other Medical Conditions:

ex. Diabetes, Epilepsy, Drug Allergies.... anything that might be critical for us or a medical practitioner to know in the event of an emergency.

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Insurance Information

Insured's Name: *

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Insurance Carrier: *

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Group Number: *

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Provider Number: *

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Additional Insurance Info:

Any Additional plans you are covered under & the information regarding those.

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Practice Availability

Sunday

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Monday

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Tuesday

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Wednesday

The content of this field is kept private and will not be shown publicly.

Thursday

The content of this field is kept private and will not be shown publicly.

Friday

The content of this field is kept private and will not be shown publicly.

Saturday

The content of this field is kept private and will not be shown publicly.

Terms and Conditions of Use

Terms & Conditions:

By accessing “Ann Arbor Roller Derby” (hereinafter “we”, “us”, “our”, “Ann Arbor Roller Derby”, “http://www.a2derbydimes.org/”), you agree to be legally bound by the following terms. If you do not agree to be legally bound by all of the following terms then please do not access and/or use “Ann Arbor Roller Derby”. We may change these at any time and we’ll do our utmost in informing you, though it would be prudent to review this regularly yourself as your continued usage of “Ann Arbor Roller Derby” after changes mean you agree to be legally bound by these terms as they are updated and/or amended. Our forums are powered by Drupal (hereinafter “they”, “them”, “their”, “Drupal software”, “www.drupal.orr") which is a content management system released under the “General Public License” (hereinafter “GPL”) and can be downloaded from www.drupal.org. The Drupal software only facilitates internet based discussions and the presentation of user content, Drupal is not responsible for what we allow and/or disallow as permissible content and/or conduct. For further information about Drupal, please see: http://www.drupal.org/. You agree not to post any abusive, obscene, vulgar, slanderous, hateful, threatening, sexually-orientated or any other material that may violate any laws be it of your country, the country where “Ann Arbor Roller Derby” is hosted or International Law. Doing so may lead to you being immediately and permanently banned, with notification of your Internet Service Provider if deemed required by us. The IP address of all posts are recorded to aid in enforcing these conditions. You agree that “Ann Arbor Roller Derby” have the right to remove, edit, move or close any topic at any time should we see fit. As a user you agree to any information you have entered to being stored in a database. While this information will not be disclosed to any third party without your consent, neither “Ann Arbor Roller Derby” nor Drupal shall be held responsible for any hacking attempt that may lead to the data being compromised.

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Money Raised as of 6/17/2011:

$10,905