Referee Information - Pot O' Gold 2012

Teams are REQUIRED to provide three (3) QUALIFIED referees; enter information for each one separately
If you have not completed all Required fields, you will get an Error Message
Full Name (required) First Name   Last Name
Address  
City    State   Zip
Phone Numbers (nnn) nnn-nnnn Home (required)   Other (type)  ( )
E-Mail Address  
National AYSO ID#  
AYSO Region # (required)
Your Regional Referee Administrator (Area Referee Admin for U16/U19 refs; required):
Full Name    E-Mail or Phone  
Coaches:  If you are completing this info for a referee representing your team, you MUST select "Yes"
AND select your team # from the Team #1 dropdown list below.
Coaches do NOT use Team #2 or Team #3.
Have you confirmed with this Referee that he or she is willing AND available for this Tournament?
Designated Team Referee for a team or teams in this Tournament (Y or N)?    Team #1    Team #2    Team #3
Child on this team?  Select "Yes" if you prefer to NOT be assigned to a match when this Team is scheduled to play.  
Referee Data  (required): Youth/Adult    Badge (year)   ()

*** Youth Referees are required to complete a Tournament Youth Referee Letter ***
# of Years as an AYSO Referee  
Highest level match you feel comfortable with as a Center Ref(required)  

What day(s) and time(s) are you available?  Y or N for each time period

Boys Week 1: 

Sat 3/17 AM     Sat 3/17 PM     Sun 3/18 AM    Sun 3/18 PM

Girls Week 2:

Sat 3/24 AM     Sat 3/24 PM      Sun 3/25 AM     Sun 3/25 PM

U16/19 Week 3:

Sat 3/31 AM      Sat 3/31 PM      Sun 4/1 AM     Sun 4/1 PM

Notes/Comments/Requests  

1. Be sure that ALL information is complete
2. BEFORE YOU CLICK THE <ADD> BUTTON BELOW!
Use the Print function of your browser to print this Form for RRA/ARA signature (Page Setup:  Portrait, .25" margins)
3. Click here to send Referee information to POG staff---->  

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-19 games as indicated above.

Region or Area Referee Administrator:  Print Name ____________________________

Signature ________________________________  Date ___/___/______

Best way to contact you (the RRA/ARA) (evening phone number; e-mail address):

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