2022 Kanga Cup Local Referee Registration Form

1
Are you a registered Referee or Referee Assessor 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
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
9
Do you have any medical conditions (including allergies)?* This field is required.
YesNo
10
Please list any medical condition(s) including allergies.* This field is required.
11
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
12
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
13
Referee Assessor Qualification* This field is required.Please select your current Referee Assessor qualification.
N/A
-
Referee Assessor Level 3
Referee Assessor Level 2
Referee Assessor Level 1
14
Year of Referee Qualification* This field is required.What year was your referee qualification certified?
15
When can you commit to coaching during the Tournament?* This field is required.Please select the timeslot(s) you can commit to coaching on each day of the Tournament. If you cannot commit any time to coaching on a day, please select 'Can't Commit' option only.
Can't Commit
8.30am - 11.30am
11.30am - 2pm
2pm - 4.30pm
Monday 8th
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Tuesday 9th
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Wednesday 10th
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Thursday 11th
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Friday 12th (Grand Final)
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Monday 8th
Tuesday 9th
Wednesday 10th
Thursday 11th
Friday 12th (Grand Final)
Can't Commit
Row 0, Column 0
8.30am - 11.30am
Row 0, Column 1
11.30am - 2pm
Row 0, Column 2
2pm - 4.30pm
Row 0, Column 3
Can't Commit
Row 1, Column 0
8.30am - 11.30am
Row 1, Column 1
11.30am - 2pm
Row 1, Column 2
2pm - 4.30pm
Row 1, Column 3
Can't Commit
Row 2, Column 0
8.30am - 11.30am
Row 2, Column 1
11.30am - 2pm
Row 2, Column 2
2pm - 4.30pm
Row 2, Column 3
Can't Commit
Row 3, Column 0
8.30am - 11.30am
Row 3, Column 1
11.30am - 2pm
Row 3, Column 2
2pm - 4.30pm
Row 3, Column 3
Can't Commit
Row 4, Column 0
8.30am - 11.30am
Row 4, Column 1
11.30am - 2pm
Row 4, Column 2
2pm - 4.30pm
Row 4, Column 3
1 of 5
16
Venue Commitment - Monday 8 July to Thursday 11 July* This field is required.Please select the region you can commit to
Please Select
Please Select
Northside
Southside
Both
17
Referee Coach Commitment - Additional CommentsPlease enter any comments in relation to your commitment as a Referee Coach or travel limitations during the Tournament.
Huge
Large
Normal
Small
Ok
Ok
18
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 2024 Kanga Cup.

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

Click next to continue your registration.
19
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 Local Referee Coaches Meeting at a date to be confirmed in preparation for the Tournement.
I agree to contact the Kanga Cup Organising Committee immediately if I have to withdraw from officiating at the Kanga Cup.
20
Signature* This field is required.
Clear
Should be Empty: