2022 Kanga Cup Local Referee Registration Form

1
Are you a registered Referee or Game Leader with Capital Football?
Yes
No
2
Please name the Member Federation or Referee Association that you are registered with.
3
Full Name* This field is required.Please enter your full name.
First Name
Last Name
4
Gender* This field is required.Please select your gender.
Female
Male
Non-Binary / Gender Fluid
5
Date of Birth* This field is required.Please enter your date of birth.
Date
Day
Month
Year
6
E-mail* This field is required.Please enter the primary email address that all correspondence should to be sent to.
7
Phone Number* This field is required.Please enter the preferred phone number to contact you.
8
Address* This field is required.Please enter the details of where you live.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Australia
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
Emergency Contact Details* This field is required.Please provide the contact details of your emergency contact.
Full Name of Emergency Contact
Email address of Emergency Contact
Phone Number of Emergency Contact
10
Do you have any medical conditions (including allergies)?* This field is required.
YesNo
11
Please list any medical condition(s) including allergies.* This field is required.
12
How long have you been refereeing?* This field is required.
Less than 1 year
1-2 years
3-4 years
4-5 years
6-8 years
9+years
13
Referee Qualification* This field is required.Please select your current referee qualification.
Game Leader
Referee Level 4
Referee Level 3
Referee Level 2 (Theory)
Referee Level 2
Referee Level 1 (Theory)
Referee Level 1
14
Year of Referee Qualification* This field is required.What year was your referee qualification certified?
15
Referee Experience - Last 2 Years* This field is required.Please outline your experience as a Referee / Game Leader in the last two years.
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Large
Normal
Small
Ok
Ok
16
Assistant Referee Experience - Last 2 Years* This field is required.Please outline your experience as an Assistant Referee in the last two years.
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Large
Normal
Small
Ok
Ok
17
Venue Commitment - Monday 3 July to Thursday 6 July Please select the region you can commit to from Monday 3 July to Thursday 6 July.
Please Select
Please Select
Northside
Southside
Both
18
Grand Final Day - Friday 7 July* This field is required.Can you commit to Southwell Park on Friday 9 July 2021 for Grand Final Day?
Please Select
Please Select
No
Yes
19
Venue Commitment - Additional CommentsPlease enter any comments in relation to travelling to venues during the Tournament.
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Large
Normal
Small
Ok
Ok
20
Are you playing for a team during the Tournament?
No
Unsure
Yes
21
Please enter the name of the Team that you are playing with during the Tournament.e.g U14 Tigers FC (Cup / Plate / Shield)
22
Please note that if you are aged 16 years or older, you will need to obtain an ACT Government Working With Vulnerable People Registration (WWVP) before officiating at the 2023 Kanga Cup.

You can apply for a WWVP registration via the Access Canberra website.

Click next to continue your registration.
23
Terms and Conditions* This field is required.
I agree to abide by the rules of Capital Football for the operation of Match Officials for the Kanga Cup.
I understand I will be required to attend a Tournament Meeting on Sunday 3 July 2022 in preparation for the Tournament.
I agree to contact the Kanga Cup Organising Committee immediately if I have to withdraw from officiating at the Kanga Cup.
24
Signature* This field is required.
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