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) 433-2010Application Date* Membership Application Year*Application Type*RenewalNew MemberMembership Application Type*Adult, $60.00 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* Home PhoneWork PhoneCell Phone*Current USSF Referee Grade*Please enter a value 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.*YesNoI understand that live scan finger printing approval through the California Department of Justice is required to officiate youth games.*YesNoI will not officiate soccer matches in which I have a conflict of interest in the outcome*YesNoI will use the Arbiter Assignment System to block games in which I have a conflict of interest (Training available).*YesNoSignatureBy 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 ProceduresDate* For Office UseRecieved ByOnAdded to Arbiter OnByReceived Dues AmountOnBy This iframe contains the logic required to handle AJAX powered Gravity Forms.