Referee Candidate Application
Full Legal Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
You are in the Southeast Region
Your Regional Coordinator is Elaine Roden (elaine@rowmiamibeach.com)
You are in the Southwest Region
Your Regional Coordinator is Bryan Fraser (b_fraser1@u.pacific.edu)
You are in the Northwest Region
Your Regional Coordinator is Kathleen Crowe (kmcuervo@gmail.com)
You are in the Northeast Region
Your Regional Coordinator is Jim Dwyer (waterchem@msn.com)
You are in the Midwest Region
Your Regional Coordinator is Blake Ebright-Jones (blake.ebright@gmail.com)
You are in the Mid-Atlantic Region
Your Regional Coordinator is Mike Murphy (ashmurph5@gmail.com)
You are in the: (This section will automatically fill based on the state you live in.)
Birthdate Date
-
Month
-
Day
Year
Date
Gender
Female
Male
Non-Binary
Other
Prefer not to say
USRowing Membership Number
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Mentor's Name
First Name
Last Name
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you had a background check in the past 2 years? (If not we will provide you with one.)
Yes
No
Have you completed SafeSport Core Trained Course, or it's applicable refresher course in the past 365 days? (If not we will provide you with the training.)
Yes
No
Submit
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