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
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
Junior Football Match Official (Level 4)
Senior Football Match Official (Level 3)
Emerging Education (Level 2 Theory)
Emerging Referee (Level 2)
Advance Education (Level 1 Theory)
Advanced Referee (Level 1)
13
Year of Referee Qualification* This field is required.What year was your referee qualification certified?
14
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
15
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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Normal
Small
Ok
Ok
16
Venue Commitment - Monday 14 July to Thursday 17 JulyPlease select the region you can commit to.
Please Select
Please Select
Northside
Southside
Both
17
Grand Final Day - Friday 18 July* This field is required.Can you commit to Southwell Park for Grand Final Day?
Please Select
Please Select
No
Yes
18
Venue Commitment - Additional CommentsPlease enter any comments in relation to travelling to venues during the Tournament.
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Normal
Small
Ok
Ok
19
Are you playing for a team during the Tournament?
No
Unsure
Yes
20
Please enter the name of the Team that you are playing with during the Tournament.e.g U14 Tigers FC (Cup / Plate / Shield)
21
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 Kanga Cup.

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

Click next to continue your registration.
22
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 13 July 2025 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.
23
Signature* This field is required.
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