Officials - Sask First Para Program

Applicant Information

At camp, I would prefer to work as a, *

First Name *

Last Name *

Birthdate *

Email *

Address *

Town/City *

Postal Code *

Home Phone (000) 000-0000 *

Work Or Cell Phone (000) 000-0000 *

Highest level you have officiated as a REFEREE *

Highest level you have officiated as a LINESPERSON *

Health Card Number *

Emergency Contact Name *

Emergency Contact Relationship To Official *

Emergency Contact Address *

Emergency Contact Phone Number (000) 000-0000 *

Are You Currently Taking Medication? *

If Yes, Please Provide Type Dosage *

Asthma? *

Diabetes? *

Heart Condition? *

Any Known Allergies? *

If Yes, Please List *

Hearing Aid? *

Contact Lenses? *

Concussion History *

Surgeries In The Last 5 Years *

Illnesses In The Last 5 Years *

Other Comments

MEDIA RELEASE AND CONSENT AGREEMENT: I, the parent/guardian, consent for my child to be included in photographs, video, print and/or other similar material and further agree to the use and distribution of the Materials, and any copies, for advertising purposes in any Hockey Saskatchewan publications or other media. * Yes

All officials who apply and are certified will be accepted to the camp. Future communication will be sent closer to the clinic date.

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