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NCSRA Ref Coach Submission
Ref coaches and mentors use this form to submit completed assessments and invoice NCSRSA for payment
Ref Coach First Name
*
Ref Coach Last Name
*
Ref Coach Email
example@example.com
Ref Coach Contact Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Evaluator Grade
*
Mentor
Ref Coach
Natl Ref Coach
Type option 4
Responsible Payor for Assessment
NCSRA
Other Entity
Other
Event Type
NCYSA State Cup
NCASA Carolinas Cup
NCYSA ODP event
Regular season match
USL game
Other
Game Evaluated Date
*
-
Month
-
Day
Year
Date Picker Icon
Arbiter Game Site
*
Assessment Type
*
Live on site
Video Live
Video Delayed
Game level
*
Please Select
U15 B
U15 G
U16 B
U16 G
U17 B
U17 G
U18 B
U18 G
U19 B
U19 G
U20 B
U20 G
1st Div Men
1st Div Women
Over 30 M
Over 30 W
2nd Div M
2nd Div W
Rec Men
Rec Women
Coed Rec
Other
Competition Type/League
*
Officials Evaluated
*
Please Select
Referee
Ref & AR1
Ref & AR2
All Officials
AR1
AR2
Referee Name
*
Referee Score (if assessed)
AR1 Name
*
AR1 Score (If assessed)
AR2 Name
*
AR2 Score (If Assessed)
Primary purpose of evaluation
*
Please Select
Developmental
Grade Maintenance NC St. Ref
Grade Maintenance Reg Ref
Grade Maintenance Nat Ref
Upgrade NC St Ref
Upgrade Reg Ref
Upgrade Nat Ref
Year Assessment to be Applied
*
Please Select
2026 (1-1-25 to 6-30-26)
2027 (1-1-26 to 6-30-27)
Mileage to be paid?
*
Please Select
Yes
No
Mileage cost #miles x $.65 if requesting reimbursement
Meals expense? (upload receipts at the end of the form)
*
Please Select
Yes
No
Lodging expense? (upload receipts at the end of the form)
Yes
No
Upload completed assessment files and any receipts (up to 5 files)
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