Ken Aston Camps – Registration Form apadley Course*Please selectIntermediate Referee CourseAdvanced Referee CourseNational Referee CourseReferee Instructor CourseAssessor CourseNational Referee Assessor CourseAdvanced Referee Instructor CourseName* First Last Gender*MaleFemaleDate of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920(You must be 18 to attend.)Address* Address City StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State Zip Home Phone*Cell Phone*Email* Enter Email Confirm Email AYSO ID*AYSO Section*Please select1234567891011121399AYSO Area*Please selectABCDEFGHIJKLMNOPQRSTUVWXYZAYSO Region*Lodging*ResidentCommuterPlease select if you will be attending camp as a Resident or you plan to Commute in each day. Note: Smoking is NOT permitted in any University building or during outdoor classes!Roommate RequestNO COED DORMS AVAILABLEHealth Insurance Company*Emergency Contact*Contact Home Phone*Contact Cell Phone*Soccer Referee Experience*Select years of experience0 years1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 yearsMore than 20 yearsLast Year's Experience*Please selectU10U12U14U16U19OtherWhat level did you officiate MOST last year?AYSO Volunteer Experience*Select years of experience0 years1 year2 years3 years4 years5 years6 years7 years8 years9 years10 years11 years12 years13 years14 years15 years16 years17 years18 years19 years20 yearsMore than 20 yearsCurrent Referee Badge*Please selectRegionalIntermediateAdvancedNationalNoneDate you received current badge*(mm/yy)How many times have you taught in a Referee Course?*Please select012345678910More than 10What topics did you teach?*How many referee observations have you done?*Please select012345678910More than 10Are you currently certified as a Referee Assessor?*YesNoHow many Assessments did you do in the last 3 years?*Please select012345678910More than 10What level did you officiate MOST last year?What percentage did you recommend for upgrade?*Please select0%10%20%30%40%50%60%70%80%90%100%WAIVER OF LIABILITY AND ACKNOWLEDGMENT OF DISCLAIMERTo induce the American Youth Soccer Organization (AYSO) to accept registration and permit participation at the camp I, the participant, hereby give my consent and agree to release, indemnify and hold harmless AYSO, its officials and representatives, from any claim arising out of injury to myself. I also hold harmless AYSO, its officials and representatives, from any claim arising out of injuries or conditions caused or aggravated by my refusal to obtain medical treatment based on religious or philosophical beliefs.Agreement to the Waiver of Liability and Acknowledgment of Disclaimer* I Agree Electronic Signature*Type your name to agree to the Waiver of Liability and Acknowledgment of Disclaimer and to Authorize Emergency Care, if needed.PaymentWould you like to pay online now?*Yes I'll pay online nowNo I'll send a checkIntermediate Referee Course Fee* Price: $250.00 Advanced Referee Course Fee* Price: $250.00 National Referee Course Fee* Price: $250.00 Referee Instructor Course Fee* Price: $250.00 Assessor Course Fee* Price: $225.00 National Referee Assessor Course Fee* Price: $225.00 Advanced Referee Instructor Course Fee* Price: $250.00 Late Fee $40.00 Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.