Request for Referee Evaluation

Request for Referee Evaluation
For an evaluation request please complete the following immediately (same day you receive your assignment)
1. Fill out request form below. (Please review information for accuracy) NOTE: You may add comments in the last box.
2. Press the "Submit Request" button below. (Form goes directly to the Referee Coach assignor)
3. You will be contacted once an Referee Coach / Mentor has been assigned to you.
  Important Note: Please make sure your entire referee team for that game is currently on the ROL.
Assessment Fee Schedule

Assessment by Mentor - $100
Assessment by Referee Coach - $150
Assessment by National Referee Coach - $200

For additional evaluation questions, please contact Rick Rehm at rrehm@calsouth.com.
Evaluation Date*

YearMonthDay
Date
Game Time*

:HourMinutesAM/PM Option
Upgrade?*
Game level?*
Present License Level*
Type of Evaluation*
Referee Name*

First NameLast Name
Referee Email*
example@example.com
Phone Number*

Area CodePhone Number
Assignor Name*

First NameLast Name
Field Name*
Field Number*
Field Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Information
Should be Empty: