REFEREE COURSE - APPLICATION FORM

REFEREE COURSE - APPLICATION FORM
Thank you for your interest in completing a referee Course. We are looking for applicants who will complete all elements of the course and become active referees.
1. APPLICANT DETAILS
Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Postcode:
Telephone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
Emergency Contact:

Full NameTelephone
2. BASKETBALL EXPERIENCE
Are you currently involved with a basketball club?
If yes, Club Name:
Team/Age Group:
Role:
Have you previously refereed basketball games?
If yes, please provide details:
3. REFEREE COURSE
Why would you like to complete the referee course?
4. DECLARATION
I confirm that the information provided is accurate to the best of my knowledge. I understand that completing this application does not guarantee a place on the course.
I understand that I need to complete both the online and practical elements of the referee course.
I confirm that, on completion of this referee course, I am looking to actively referee in leagues in the South and Wessex.
Applicant Name:

First NameLast Name
Applicant Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
5. PARENT/GUARDIAN CONSENT (UNDER 18)
Parent/Guardian Name:

First NameLast Name
Relationship to Applicant:
Telephone Number:
Format: (000) 000-0000.
Email Address:
example@example.com
I give permission for the above-named applicant to participate in this referee course.
Parent/Guardian Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

REFEREE COURSE - APPLICATION FORM

1. APPLICANT DETAILS

2. BASKETBALL EXPERIENCE

3. REFEREE COURSE

4. DECLARATION

5. PARENT/GUARDIAN CONSENT (UNDER 18)