RETURN THIS PAGE ASAP TO:

Merry Hilger, 9834 Palm St. NE, Coon Rapids, MN  55433

 

Blackhawks, Cambridge-Isanti, Centennial, Hopkins, Forest Lake, Minnesota Revolution, Newcastle,

NSSA, Northern Lights, North Metro, Princeton, Over 40 League and White Bear Lake

2008

REFEREE INFORMATION AND WAIVER FORM

 

I,                                              , am a certified USSF referee and I am an independent contractor and not an employee of the above Soccer Clubs or M & D Sports.  I am a grade                  referee.  Grade 9 blue patch, Grade 8 black patch.

 

As an independent contractor, I am aware that I am solely responsible for providing worker’s compensation insurance for myself and will not hold the above Soccer Clubs or M & D Sports responsible for any injury, which may occur while refereeing a soccer game.

 

                                                                                                                                                                            

                                                                                    (Signature)

 

By signing this agreement, I give my minor child permission to referees soccer games for the listed Soccer Clubs. 

 

                                                                                                                                                                            

                                                                                    (Parent signature if under 18)

 

PLEASE PRINT THE FOLLOWING INFORMATION:

 

Name:                                                                                                                                                                

 

Address:                                                                                                                                                            

 

City, State, Zip:                                                                                                                                                  

 

Home Phone:                                       Work Phone:                                       Cell Phone:                                       

 

E-mail address                                                                                 Birth Date:                                                 

 

Years of Experience                         I am comfortable centering   U-                        and AR    U-                          

 

Clubs that I want to work for (circle)   Blackhawks            Cambridge-Isanti             Centennial               Hopkins   

 

         Forest Lake        MN Rev               Newcastle               NSSA            Northern Lights           North Metro 

   
        Princeton                      Over 40 League                                 White Bear Lake
 

***************************************************************     

 

Signing below states that I will read the “Informational Letter” and subsequent revisions thereof for each season that I am refereeing for and will ask questions if I have any.

 

                                                                                                                                                                          

                                                                                                            (Signature)