All EPA referees who are interested in refereeing at the Region 1 must complete this form. Completing this form DOES NOT mean that you have be selected, only that you are interested. EPSARC will select the referees and assessors who will represent EPA at the tournament.

Referee Name:         

Address:         

Address #2:

City:                 State:                    Zip:         

Home Phone:          xxx-xxx-xxxx        Cell Phone: xxx-xxx-xxxx

Email Address:         

Current USSF Grade:       Age: 

Numbers of Years Refereeing:  Select a number 1 2 3 4 5 More than 5

Primary Assignor Name: 

Please indicate all of the 2012 Region 1 tournaments you are interested in:

If you are selected - you must stay for the entire tournament and stay at the location selected by Region 1.

President Cup  -  will be held on the weekend of May 25^th - 28^th in New Hampshire.

I am interested in attending       Yes    No

ODP  -  Mercer County, New Jersey June 8^th thru 10^th

ODP –  Friday thru Sunday    Yes         No  

Regional 1 National Championships -  June 28^th  – July 3^rd to be held in Eastern PA  

I am interested in attending:    Yes                No

ODP Camp-  July days are TBD, location - Univ of Rhode Island  

I am interested in attending:    Yes             No

By checking the box below, I understand that I have an informing the SYRA of my interest in and that this does not mean that have been selected.

 I Understand       I Do Not Understand