Franky Panky 2016 Officiating Application

Please contact SlipperyVixenNSO@gmail.com with any questions.

Legal Name
Your answer
Derby Name
Your answer
Email address
Your answer
Telephone Number
ex. 123-456-7890
Your answer
WFTDA or MRDA Insurance
All skating officials are required to have supplemental insurance through the WFTDA or MRDA. Please provide the number below, using the appropriate format, either "WFTDA-******" or "MRDA-******." Non-skating officials are not required to have WFTDA or MRDA insurance and should designate, "NSO."
Your answer
League Affilation
Your answer
Skating Officials' Positions
Please select all in which you are interested and comfortable.
Non-Skating Officials' Positions
Please select all in which you are interested and comfortable.
Officiating Experience
Please provide a link to your officiating history spreadsheet.
Your answer
References
Please give names and contact information for two roller derby references who have worked with you within the past 12 months.
Your answer
Certification/Recognition
Certification Level
ex. WFTDA SO-L4 for a WFTDA-certified Level 4 Referee or JRDA NSO-L2 for a JRDA-certified Level 2 NSO.
Your answer
Please note if you also plan to be a skater, bench coach, announcer, or volunteer in any capacity that may affect your availability to officiate any game(s) in the event.
Your answer
Medical conditions/allergies
Your answer
Emergency Contact
Name, relationship, telephone numbers, and email address.
Your answer
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