Pleasure Island Soccer Association PO Box 1868, Carolina Beach, NC 28428
Rec Registration-Fall '19
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Referee Agreement Form
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Date of Birth
enter this format: MM/DD/YYYY. Must be at least Age 14.
Social Security #
Form will not be accepted without SS#
* Required if Referee under age 18
Email will be used as primary communication. Make sure address is typed correctly.
By clicking the Submit button below, you agree to have read the following Referee Agreement.
I am the referee, or we/ I, as the parent/legal guardian of the referee named above, do hereby declare our permission & consent to allow referee named above to participate as a referee and in programs /activities associated with the Pleasure Island Soccer Association. We/ I hereby release and hold harmless from any and all liability; Pleasure Island Soccer Association, coaches, sponsors, associated board members and personnel, and other officials, associated with this organization against any claim/ injury by or on behalf of the referee(s)’ participation in this program. We/I understand that the referee named above is not an employee, nor under the supervision/ direction of Pleasure Island Soccer Association, and is not recognized under Federal or State law as such; therefore waives any access to and is not entitled to any benefits, including but not limited to; Workers Compensation, Employer’s Liability, Employment Practices, Equal Opportunity, Disability, Medical Coverage, Hospitalization, Accidental Death & Dismemberment. I agree to abide by the rules & regulations of Pleasure Island Soccer. I will conduct myself in a professional manner, and will be fair and impartial in my judgment as a referee. I will not confront any parent, coach, child, or other participant with regard to any grievances or complaints, but instead will refer to the PISA Director with all concerns. I will notify the PISA Director of any outburst, complaint, or unsportsmanlike conduct on the part of any parent, coach, player, or other persons. Any failure to comply with the above or in a manner considered by Pleasure Island Soccer to be in the best interest of this organization may be free to discontinue at will, either on their own or by request of PISA.