Nomination for FYSA Young Referee of
the Year
Name:
_____________________________________________ Male – Female
Address:
___________________________________________
City:
_____________________________
State:____ Zip: _________________
Phone:________________________ Date of Birth: ___________________
Date first registered
with USSF: __________ USSF # __________________________
Current USSF Grade:
____ Area & District: A
B C D (circle one)
Where does he/she referee
most games: ____________________________________
Name of current
School:
Grade point average:
_______
________________________________________________________________________________________________________________________________________________
Other activities,
civic: ___________________________________________________
______________________________________________________________________
Achievements Award:
____________________________________________________
Employment: Full Time: _______ Part Time: ______ Not employed: ________
Where employed:__________________________________________________
Hobbies other than soccer:__________________________________________________
Please attach any available documents such as newspaper clippings, certificates etc.
Reason for nominating this individual for “Young Referee of the Year” _____________
_______________________________________________________________________
Name of person making the nomination:_______________________________________
Title:__________________________ E-mail address: ____________________________
Phone number: ________________________________
Date:____________________________
Signature: ________________________
Area / District: ____________________
Any variation from the above will not be
accepted.
Only the two Area finalists to be submitted to:
Attention: Referee Award Committee
Deadline to be
received at the FYSA Office: January
25.
Arrivals after this date will not be considered.