REFEREE REGISTRATION FORM

Please complete this form when any of the details listed below change

Referee Name Referee Name First Last
Date of Birth Date of Birth / DD / MM YYYY
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Email
Phone
Registration Numer (if known)
Please list the teams that you play or coach for (Team name and division)
If Under 18:
Parent's Name Parent's Name First Last
Parent's Phone
Parent's Email
In Case of Emergency:

In the case of a referee under who is under 18, we will contact the parent listed above first
Name Name First Last
Relationship
Phone
Medical - Do you have any allergies or medical conditions that I should be aware of that may affect youre ability to referee? Please list all (these details will be kept confidential)
Permission to Publish

Permission to Publish I do not give permission for my image to be used on the MWBA website, Facebook Page, Instagram Account, or in any advertising or promotional materials.
Disclaimer

Disclaimer By checking this box I acknowledge that as a member of Manly Warringah Basketball Association and a referee registered with Basketball NSW, I agree to act in accordance with the constitutions, by-laws and Codes of Conduct of both Associations, and understand that any infraction of these Codes will be addressed under the BNSW Judiciary Tribunal or the MWBA Administrative Tribunal.
Name Name First Last
Date Date / DD / MM YYYY