Referee Candidate Application

Referee Candidate Application
Full Legal Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState

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 Derek Blazo (sixseat7@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

MonthDayYear
Date
Gender

FemaleMaleNon-BinaryOtherPrefer not to say
USRowing Membership Number
Mentor's Name

First NameLast Name
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Have you had a background check in the past 2 years? (If not we will provide you with one.)

YesNo
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.)

YesNo
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