Ayso Application For Referee Certification Form Page 2
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2AYSO Application for Referee Certification
PLEASE RETAIN YOUR COPY OF THIS FORM AS YOUR RECORD OF COMPLETED TRAINING NEEDED FOR UPGRADE
Send a copy of completed form (
to the AYSO National Office
after the Area or Section Referee staff signs)
Attn: Officiating Dept. 19750 S. Vermont Ave., Suite 200 Torrance CA 90502 *or* (310) 525-1155 FAX
Name: _______________________________________ Phone:_______________ Section____ Area ____ Region__________
Address:________________________________________ City:______________________ State________ Zip_____________
Date of Birth
AYSO ID (from eAYSO):_______________________________________________
(if under 18)____________
Cumulative matches as Referee:
U8________ U10________ U12________ U14 ________ U16________ U19________
Requirement: Intermediate - 25 with 5 in U-12; Advanced - 50 with 10 in U-14; National - 100 with 30 in U-16 or U-19 (15 in U-19 if available)
Cumulative matches as Assistant Referee:
U8________ U10________ U12________ U14 ________ U16________ U19________
Requirement: Intermediate - None; Advanced - 5 in U-14; National - 25 in U-16 or U-19 (10 in U-19 if available)
Roster #
Authorizing Printed Name, Title, Signature
Date
Instructors: sign below for either
entire course or individual modules.
Intermediate Referee
CANDIDATE COMPLETED ENTIRE COURSE
Lead
Mod. 14: More Challenging Matches
Lead
Mod. 15: Fouls & Misconduct-Intermediate
Lead
Mod. 16: Offside-Intermediate
Lead
Mod. 17: Interaction with Coaches & Spectators
Lead
Mod. 18: The Referee Team & Diagonal System
Lead
Mod. 19: AYSO National Referee Program
Lead
Intermediate Referee Examination (Min. score 90%)
Tester
Observation
Observor:
Level:
Advanced Referee
Roster #
CANDIDATE COMPLETED ENTIRE COURSE
Lead
Mod. 20: Understanding the Advanced Game
Lead
Mod. 21: Offside-Advanced
Lead
Mod. 22: Fouls in the Advanced Game
Lead
Mod. 23: Misconduct: Players, Substitutes, Others
Lead
Mod. 24: Reading the Advanced Game
Lead
Advanced Referee Examination (Min. score 90%)
Tester
Fitness Test
Tester
Referee Assessment
Assessor
Level:
Asst. Referee Assessment
Assessor
Level:
National Referee
National Referee Course (Roster #)
Lead
National Referee Examination (Min. score 90%)
Tester
Fitness Test
Tester
Referee Assessment
Assessor
Level:
Referee Assessment
Assessor
Level:
Asst. Referee Assessment
Assessor
Level:
I have completed all requirements for certification as:
Intermediate
Advanced
National Referee
Applicant's Signature
Date
Intermediate Referee
Advanced Referee
National Referee
The above referee has completed all requirements for certification as:
Verifiier Position Requirement: Intermediate & Advanced - candidate's ARA or ADRA; National - candidate's SRA or SDRA
Verifier's printed name & position
Verifier's signature
Date
August 2014
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