Application Form

Membership Application for the Ventura Chapter of the

Southern California Soccer Referee Association (SCSRA)

Please fill out this application and print it once you submit the form. Incomplete applications may be rejected. Please make your dues check payable to SCSRA-Ventura and mail it with the signed application to: Bruce Russell at 1742 Caballero St., Simi Valley, CA, 93065-4814. (805) 433-2010
Application Date*
Date Format: MM slash DD slash YYYY
Membership Application Year*
Application Type*
- Renewal
- New Member
Membership Application Type*
- Adult, $65.00 Membership Fee ( 18 and Over as of 3/31 of current application year)
- Youth, $30.00 Membership Fee (Under 18 as of 3/31 of current application year)
Name*
First Middle Last
Address*
Street Address City ZIP / Postal Code
Email Address*

Required to Receive Game Assignments
Birth Date*
Date Format: MM slash DD slash YYYY
Home Phone
Work Phone
Cell Phone*
Current USSF Referee Grade*
Please enter a number greater than or equal to 1.
Latest Year Registered*
USSF ID Number*
CalSouth ID Number*
Other Association Memberships*
I Will Accept Assignments For (Check all That Apply):*
- Adult D1
- Adult D2
- U15 & Up
- U14 & Below
- Tournaments
- League Games
- Volunteer Games
New applicants please provide a brief summary of your referee experience:
Have you ever been convicted of a felony, crime of violence, any crime against an individual, or fraud? Application rejected if blank.*
- Yes
- No
I understand that live scan finger printing approval through the California Department of Justice is required to officiate youth games.*
- Yes
- No
I will not officiate soccer matches in which I have a conflict of interest in the outcome*
- Yes
- No
I will use the Arbiter Assignment System to block games in which I have a conflict of interest (Training available).*
- Yes
- No
Signature
By signing this application, I affirm that the above information is correct. I further agree to abide by the USSF Referee Code of Ethics and this Association's Constitution, By–Laws, Policies, and Operating Procedures
Date*
Date Format: MM slash DD slash YYYY
For Office Use
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Added to Arbiter On
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Received Dues Amount
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Membership Application for the Ventura Chapter of the

Southern California Soccer Referee Association (SCSRA)

For Office Use

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