2024 KCRYA Referee Application Form

1
I am registered as a Referee in:* This field is required.
Please Select
Please Select
Australia
Hong Kong
New Zealand
Other
2
FA Number* This field is required.Please enter your FA Number.
3
Name* This field is required.Please enter your full name.
First Name
Last Name
4
Gender* This field is required.Please select your gender.
Please Select
Please Select
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
Primary Email Address* This field is required.Please enter the primary email address that all correspondence should to be sent to.
example@example.com
7
Phone Number* This field is required.Please enter the preferred phone number to contact you.
Country Code
Area Code
Phone Number
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 allergies or dietary requirements?* This field is required.
YESNO
10
Please provide details of any allergies and / or dietary requirements.* This field is required.
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Ok
11
Do you have any medical conditions?* This field is required.
YESNO
12
Please provide details of any medical conditions.* This field is required.
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Ok
13
Do you take medication on a regular basis?* This field is required.
YESNO
14
Please provide details of any medications you are required to take.* This field is required.
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Ok
15
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
16
Referee Qualification* This field is required.
Please Select
Please Select
FA Junior Football Match Official (Level 4)
FA Senior Football Match Official (Level 3)
FA Emerging Education (Level 2 Theory)
FA Emerging Referee (Level 2)
FA Advance Education (Level 1 Theory)
FA Advance Referee (Level 1)
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NZF Level 1 Referee
NZF Level 2 Referee
NZF Level 3 Referee
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Other
17
Referee Qualification (Other)* This field is required.
18
Year of Referee Qualification* This field is required.What year was your referee qualification certified?
19
Referee Experience - Last 2 Years* This field is required.Please outline your experience as a Referee in the last two years.
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Ok
20
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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Ok
21
MF / Referee Branch Contact Details* This field is required.Please provide the contact details of a suitable person within your Member Federation / Referee Association who we can contact to discuss your KCRYA nomination.
Full Name of MF / Referee Branch Contact
Email address of MF / Referee Branch Contact
Phone Number of MF / Referee Branch Contact
22
Terms and Conditions* This field is required.
I confirm that the above information is true and correct.
23
Signature* This field is required.
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