Referee Form

AYSO High Valley Shootout

Referee Information Form

I plan to bring a referee team to the tournament Y/N:

Referee Information Form Date:

Region:

Team Name:

Coach Name:

Age Division:

U-10

U-12

U-14

U-16

U-19

Boys

Girls

Coed

Referee Team Contact Person

Name:

Email Address:

Day Phone:

Evening Phone:

Provide the following information for each referee.

·         For “Badge Level”, insert R = Regional, I = Intermediate, A = Advanced, N = National. Also the date they were certified at that level.

·         In each box under “Center/Assistant/Boys/Girls”, provide the highest level they are competent to referee (e.g. BU-10, GU-12, etc.)

·         In “Player on Team”, indicate if the referee has a child who is playing in the tournament on this team.

Referee Name

Badge Level

Certifica-
tion Date

Center

Assistant

Player on Team (Y/N)

Home Phone/ Email

Boys

Girls

Boys

Girls

1

2

3

4

Each referee will receive a tournament T-Shirt. Please indicate sizes needed. All sizes are Adult.

XXL

XL

L

M

S

Number of Shirts Needed

Regional Referee Administrator’s Name

Phone Number

Email

By my signature below, I certify that all referees listed are trained and Safe Haven certified AYSO referees and qualified for officiating U-10 through U-14 games as indicated above.

RRA Signature and date (Blue ink please)

Area Referee Administrator’s Name

Phone Number

Email

By my signature below, I certify that all referees listed are trained and Safe Haven certified AYSO referees and qualified for officiating U-16 and U-19 games as indicated above.

ARA Signature and date (Blue ink please)