Referee Application Referee Application Name* First Last Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Text OK? Yes No Second PhoneI am interested in refereeing:* U6 U8 U10 U12 U15 U18 Not Sure I am available* Monday Tuesday Wednesday Thursday Have you been a MMYSA referee in the past?* Yes No If so, how many years? Do you play on a MMYSA team?* No Yes, U18 Yes, U15 Yes, other Do you have family member(s) playing soccer in MMYSA? List names and division level: * I do hereby certify that I have not been convicted of a crime, which is punishable by more than two (2) years in jail, nor have I been subject of an indicated case of child abuse or a founded case of child abuse pursuant to the applicable law of the jurisdiction in which I reside and/or wish to referee. * I hereby agree that the M & M Youth Soccer Association (MMYSA), its members, coaches or officers shall not be liable for any injury or loss which I may sustain while participating in activites of any kind, whether sponsored by or under the supervision of MMYSA and I agree to indemnify and to hold harmless MMYSA, its members, coaches and officers or designates of any kind of claim whatsoever. * I hereby understand that in the event I show up to any MMYSA activity, in an impaired state, whether it be drugs, including illegal prescription drugs, or alcohol, it will be automatic grounds for dismissal, with no recourse to be taken. Electronic Signature* By typing my name above, I agree that the above information is accurate and I am the named individual applying for the position of referee through MMYSA. Δ