Application Form

Membership Application for the Ventura Chapter of the

Southern California Soccer Referees 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: Lou Mages at 2919 Camino Calandria, Thousand Oaks, CA 91360, 805-218-6906.
Application Date*
MM slash DD slash YYYY
Membership Application Year*
Application Type*
- Renewal
- New Member
Membership Application Type*
- Adult, $75.00 Membership Fee ( 18 and Over as of 3/31 of current membership year)
- Youth New Member, $0.00 Membership Fee (Under 18 as of 3/31 of current membership year)
- Youth Renewing Member, $30.00 Membership Fee (Under 18 as of 3/31 of current membership year)
Name*
First Middle Last
Address*
Street Address City ZIP / Postal Code
Email Address*

Required to Receive Game Assignments
Birth Date*
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 (if not yet registered, enter "none")*
USSF ID Number (if new enter "xxxx-xxxx-xxxx-xxxx")*
CalSouth ID Number (if new enter "xxxxx-xxxxxx")*
Other Association Memberships (if none, enter "none")*
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 fingerprinting 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*
MM slash DD slash YYYY
For Office Use
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On
Added to Arbiter On
By
Received Dues Amount
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Membership Application for the Ventura Chapter of the

Southern California Soccer Referees Association (SCSRA)

For Office Use

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