NOTE: REQUIRED FIELDS ARE MARKED WITH (*)
Officials Name: *
(first) (last)

Address:*

Town:*

Zip Code:*

E-Mail Address:*

Primary Contact Phone w/area code:*

Secondary Contact Phone w/area code:

Other Contact Phone w/area code:

Number of Years as Certified Official:*

Select Home School District:* Babylon Village Bay Shore Bayport-Blue Point Center Moriches Commack Comsewogue Connetquot Copiague Deer Park East Hampton East Islip East Moriches Eastport- Hauppauge Islip Kings Park Lindenhurst Longwood Middle Country Miller Place Mt. Sinai North Babylon North Fork North Shore Patchogue/Medford Rocky Point Sachem Sayville Shoreham- Smithtown South Counrty South Huntington South Manor South Shore SYAG Three Villages Wading River West Babylon Westhampton Beach

List any school(s) to which you should not be assigned:

School 1: School 2:

School 3: School 4:

Do you want to be scheduled as a SCGL Referee? *
YES NO

How many consecutive games are you willing to work in 1 day?

Please call me on an AS NEEDED BASIS ONLY *
YES NO

Date	Earliest Start Time AM/PM?	Latest Start Time AM/PM?
Sunday, April 11th
Sunday, April 18th
Sunday, April 25th
Sunday, May 2nd
Sunday, May 9th
Sunday, May 16th
Sunday, May 23rd
Sunday, June 6th
Saturday, June 12th SCGL Jamboree - All Day
Sunday, June 13th Rain Make Up Date

Once you receive your schedule you must confirm your acceptance of games.
Check the SCGL web site for ALL weather related cancelations.
This is YOUR responsibility.
DUE BY: MARCH 22nd



Please enter any additional comments here: