Club Independent Soccer Club - BECOME A REFEREE REGISTRATION (CI) (2019-2020)

Seasons

BECOME A REFEREE REGISTRATION (CI) (2019-2020)

Since there is a referee shortage in the state of Alabama, CI is adopting a “CI Become a Referee” program. If a new referee candidate signs up for the “CI Become a Referee” program, completes the Grade 8 certification and receives the official referee badge, CI will reimburse the candidate $40. In return, the new referee will agree to referee at least 8 CI games in the next 12 months.

*Referee Candidate Name:

Name:

*Referee Candidates Phone Number:

*Referee Candidates Email Address:

*Referee Candidates Birth Year:

*Referee Candidates Address:

Street Address:
City: State/Province: Country: Zip/Postal Code:

If the referee candidate is under 18 years of age, please fill out Parent(s) Name:

Name:

If the referee candidate is a under 18 years of age, please fill out Parent(s) Phone Number:

If the referee candidate is under 18 years of age, please fill out Parent(s) Email Address:

*Any Previous Experience as a Volunteer Referee:

*Previous Soccer Playing Experience:

Agreement to Referee CI Games:

I agree to referee 8 CI games minimum in the 12 months following the receipt of my referee badge/training certification.

*Referee Candidates Name:

Name:

*Date:

*Referee Candidates Physician:

Name:

*Physician’s Number:

Emergency Contact:

In an emergency, when parent(s) or legal guardian(s) cannot be reached, please contact:

*Emergency Contact Name:

Name:

*Home Phone Number:

*Cell Phone Number:

Medical Treatment:

CONSENT FOR MEDICAL TREATMENT (MINOR) – As the referee candidate or parent or legal guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb or well-being of my dependent.

*Referee Candidate or Legal Parent or Guardian Signature (If under 18 years of age):

Name:

*Date:

Release:

I, the referee candidate/parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of Club Independent (CI), its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the Club Independent (CI) accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify Club Independent (CI), its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. In addition – I authorize my or my child’s photograph, picture or likeness, and voice to appear in any documentary, promotion (including advertising), television, video, websites, social media, and radio coverage of Club Independent (CI), without compensation.

*Referee Candidate or Legal Parent or Guardian Signature (if under 18 years of age):

Name:

*Date:

or cancel

Club Independent (CI)

Seasons

BECOME A REFEREE REGISTRATION (CI) (2019-2020)

BECOME A REFEREE REGISTRATION (CI) (2019-2020)

Agreement to Referee CI Games:

Emergency Contact:

Medical Treatment:

Release:

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