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Student Worker Application

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Name:

Campus Phone Number:

Cell Phone with Voicemail:

E-mail:

Home Phone with Voicemail:

AREAS YOU ARE INTERESTED IN OFFICIATING

Check all that apply.:

Basketball

Broomball

Flag Football

In-line Hockey

Indoor Soccer

Soccer

Volleyball

CERTIFICATIONS

Check any/all that apply:

First Aid

Advanced First Aid

Life Guard

CPR

Other

Date of Lifeguard Certification (if applicable):

Date of CPR Certification Expiration (if applicable):

Other Certifications:

BACKGROUND INFORMATION

High School sports you participated in:

Have you ever been an official?:

yes

no

If yes, which sport?:

Other information or qualifications that you would like to share: