PERSONAL INFORMATION

(PRINT LEGIBLY)

 

Full Name:______________________________________________________                                                                                                                                                                                                                                                                 please be sure to include Jr., Sr., I, II, etc. if applicable)

Street Address: _______________________________________

 

City, State, Zip: _______________________________________

 

E-Mail Address: _______________________________________

 

 

Home Phone #: _______________________Cellular Phone #: _______________________________

 

 

Pager #: _______________________________ Fax #: _______________________________

 

 

 Work #: _______________________________ Extension: _______________

 

 

Other #: _______________________________ Location: _______________

 

Birth Date: ____________________             Social Security #: _____________________________

 

School your attending now (if applicable): _______________________________

 

Year in School: _________________

 

 

Will you or any family members (brothers, sisters, children, parents, spouse) be participating (coach,

player, board member, etc.) in any Leagues/Schools, etc. that we service? If so, please explain in

detail.

 

 

 

 

please use the back side of the page if additional information is needed to answer.

 

 

 

 

 

EXPERIENCE

 

Please describe your past and length of experience in officiating/umpiring in any sport

 

 

 

MISCELLANEOUS

 

How many games do you want to work a week?

1-2    3-5    5+

Are you willing to work tournaments?

YES     NO

 

Would you be willing to mentor a younger and/or less experienced official?

 (Officials with 5+ years of umpiring)     YES   NO

 

Are you currently an IHSA or ASA official? If “yes” please list your ID Number and Sports that you are certified in.

YES   NO       ID #:____________________________

 

 

Please list your other jobs, activities, recreational activities etc. Please attempt to make clear how much

time you devote/are willing to devote to officiating.  Also include any information you think would be

beneficial for application to the Association.

 

 

 

 

A background check may be completed on all new members.

 

Have you ever been convicted of a felony? If “yes” please explain.

 

 

 

 

 

 

please use the back side of the page if additional information is needed to answer.

 

 

AFFADAVIT

 

All the above information is true and accurate to the best of my knowledge, and I have not falsified any of the above information. Any false information will result in termination of services for the LWOA.

I authorize the LWOA to have a background check conducted.

I understand that my services as an official with the Lincoln-Way Officials Association are provided as an

independent contractor and that no medical insurance, workers compensation, unemployment insurance, or other benefit is accorded to me.

I understand that I assume all liability for injury to myself and waive any claim for any injury, loss, or damage against any of the organizations (Leagues/School, etc.) that we service or the Lincoln-Way Officials Association which may be sustained by me during any contest.

 

Applicant Signature: _________________________________________________________

 

Applicant Printed Name: _________________________________________________________

 

Date:   ________________

 

Parent or Guardian Signature:

 

_________________________________________________________

 

 

if applicant is under age 18 Parent or Guardian Printed Name:

 

___________________________________________

 

Date:__________________