2017RWSC Referee Form

All RWSC referees must complete and return this form in order to be eligible to be scheduled to work MYSA soccer games. This information is required for identification and is needed to provide complete contact information.

In addition, parent(s) or guardians of referees under 18 years of age must complete and sign the bottom of the form to provide consent for their child to work as an independent contractor RWSC.

By submitting this form, you (referee) are applying to be an independent contractor (not an employee) to referee soccer games as assigned by RWSC, declaring that the information submitted is true and accurate, and agreeing to the age-related conditions as listed on page 2 of this form.

Name: ______Age:______

Address: ______

Years of referee experience: ______Date of last certification: ______

License Grade: ______USSF# : ______

Background Check Completed? (18 yrs and older) ______

Concussion Training Completed? ______Please forward the completion certificate to the contact above.

Team Conflicts

  • Are you a youth player? Yes ____No ___

Club and Team ______

  • Parent of a youth player? Yes____ No ___

Club and Team (child #1) ______

Club and Team (child #2) ______

  • Coach of a Youth team? Yes ____ No ____

Club and Team ______

Please list other soccer clubs you are registered with as a referee:

************ Please note that the primary mode of communication between assignor and referees regarding scheduling will be through GameOfficals.net *********

______

Referee Signature: ______Date ______

NOTE: If Referee is under age 18, parent/guardian must complete and sign below.

This should be the parent/guardian that will be primarily responsible for the child and can be contacted regarding schedule changes, if needed.

As parent/guardian, I have read this registration form and the age-related conditions, declare that the information submitted is true and accurate, give permission for my child to referee as an independent contractor for RWSC, and will accept responsibility for my child’s safety and supervision before and after the game(s) that he/she referees.

Parent/Guardian Name: ______

Relationship: ______

Phone: (h) ______(c) ______(w) ______

Parent/Guardian Signature: ______Date: ______

Age-related Conditions:

  • If you are under 18, a parent/guardian must provide information and consent to your being a referee as an independent contractor with RWSC, and agree that he/she will be primarily responsible for your safety and supervision before and after games.
  • If you are under the age of 16, legal limitations include:
  1. No games before 7:00am or after 9:00pm
  2. No more than 40 hours a week nor more than 8 hours in a 24 hour period.
  3. No games during school hours, while school is in session.

Mail completed form to:

Timothy Nevitt

28519 Flower Valley Rd

Red Wing MN 55066

CONTACT INFORMATION

Cell 651-301-9277

Cell 651-301-1192

Home 651-388-0518

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