PYSC Referee Application
Please fill in the information below no later than March 1st of this year.  Referees below the age of 18 require a work permit on file with the referee coordinator before any games will be assigned.  Please see the PYSC Referee webpage http://www.pulaskiyouthsoccer.com/referees.html for more information on obtaining a work permit.
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First Name *
Middle Initial
Last Name *
Address
Street Address *
City *
State *
Zip Code *
Personal Information
Date of Birth *
MM
/
DD
/
YYYY
Age as of June 1st this year *
Driver License # and State license is issued by
Example: A123-4567-8910-11 WI
Contact Information
Email Address *
All communication will be via e-mail. Please provide one that is checked frequently!
Home Phone Number
Enter number as ###-###-####
Cell Phone Number
Enter number as ###-###-####
Emergency Contact Information
Please supply the Name, relationship and phone number of someone to contact in the event of an injury to the referee or other emergency event.
Emergency Contact Name *
Emergency Contact Relationship *
Emergency Contact Phone Number *
Medical Condtions / Allergy *
If none, please fill in NONE
Personal History
SAY or PYSC, at their discretion, may use the below information to conduct a criminal background check regardless of the responses in this section.
I am a returning referee. *
My Personal History __________ changed since last year *
If you are a new referee please answer HAS
Have you ever been found guilty by a court or other tribunal to have committed a violent act against another person, engaged in any misconduct involving a juvenile OR been convicted of a crime except for a minor traffic violation? *
Electronic Signature *
As an applicant for a Soccer Association for Youth (SAY), Pulaski Youth Soccer Club (PYSC) Referee position, I hereby attest to the truthfulness of the representations I have made, including the information provided in response to the questions regarding my criminal history. I authorize SAY or PYSC to verify the above information and waive any right to confidentiality with respect to the information requested. If requested by SAY or PYSC, I will submit my fingerprints for that purpose.  If so please type "I AGREE"
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