Referee Availability Form Eddie Pena-USSF Referee Assignor P.O. Box 270394 Tampa, FL 33688 Phone: 813-961-7701 Fax: 813-961-7701 Email: Epena5@tampabay.rr.com Website: http://www.edpena.net To submit online, log on to http://www.edpena.net Last Name: ____________________________ First Name: _________________________________ Address: _______________________________________________ City: ___________________ State: ________ Zip: _________ Date of Birth ___________ Gender Male ____ Female ____ FYSA Certified: Yes __ NO __ USSF Registered: yes __ or No __ Current Referee Grade: _____ Date Attained: ________ Phone Cell:(___) ____-_____ Home: (___) ____-_____ Work: (___) ____-_____ Email: _____________________________________________ Fax: (___) ____-_____ If affiliated with a Club: ____________________________________ Team: ________________________ Division: ______ Age Group: _____ Days and Times you are available: ******************************************************************** 28-Aug AM ____ PM ____ at RSL Fla. vs. Strictly Soccer Sep 11 AM ____ PM ____ at Brandon vs. CF Kraze/Krush AM ____ PM ____ at HC United vs. Fusion FC AM ____ PM ____ at FC Sarasota vs. RSL Fla. AM ____ PM ____ at Strictly Soccer vs. Lakeland FC AM ____ PM ____ at Clearwater vs. IMG Sep 18 AM ____ PM ____ at Lakeland FC vs. Clearwater AM ____ PM ____ at HC United vs. CF Kraze/Krush AM ____ PM ____ at Strictly Soccer vs. FC Sarasota AM ____ PM ____ at Fusion FC vs. Brandon AM ____ PM ____ at IMG vs. RSL Fla. Sep 25 AM ____ PM ____ at FC Sarasota vs. Clearwater AM ____ PM ____ at CF Kraze/Krush vs. Fusion FC AM ____ PM ____ at IMG vs. Strictly Soccer AM ____ PM ____ at HC United vs. Brandon AM ____ PM ____ at Lakeland FC vs. RSL Fla. Oct 2 AM ____ PM ____ at Fusion FC vs. Clearwater AM ____ PM ____ at RSL Fla. vs. Brandon AM ____ PM ____ at FC Sarasota vs. HC United AM ____ PM ____ at CF Kraze/Krush vs. Strictly Soccer AM ____ PM ____ at Lakeland FC vs. IMG Oct 9 No Games Oct 16 AM ____ PM ____ at Clearwater vs. Brandon AM ____ PM ____ at IMG vs. FC Sarasota AM ____ PM ____ at Fusion FC vs. Strictly Soccer AM ____ PM ____ at Lakeland FC vs. HC United AM ____ PM ____ at CF Kraze/Krush vs. RSL Fla. Oct 23 AM ____ PM ____ at Clearwater vs. Strictly Soccer AM ____ PM ____ at Brandon vs. Lakeland FC AM ____ PM ____ at IMG vs. Fusion FC AM ____ PM ____ at HC United vs. RSL Fla. AM ____ PM ____ at FC Sarasota vs. CF Kraze/Krush 2011 AM ____ PM ____ at Clearwater vs. CF Kraze/Krush AM ____ PM ____ at Brandon vs. IMG AM ____ PM ____ at Srictly Soccer vs. HC United AM ____ PM ____ at FC Sarasota vs. Lakeland FC AM ____ PM ____ at Fusion FC vs. RSL Fla. 2011 AM ____ PM ____ at Clearwater vs. HC United AM ____ PM ____ at Brandon vs. FC Sarasota AM ____ PM ____ at CF Kraze/Krush vs. IMG AM ____ PM ____ at Lakeland FC vs. Fusion FC 2011 AM ____ PM ____ at HC United vs. IMG AM ____ PM ____ at CF Kraze/Krush vs. Lakeland FC AM ____ PM ____ at Strictly Soccer vs. Brandon AM ____ PM ____ at Fusion FC vs. FC Sarasota AM ____ PM ____ at RSL Fla. vs. Clearwater ******************************************************************** Fri From: ____AM To: ____PM Sat From: ____AM To: ____PM Sun From: ____AM To: ____PM Mon From: ____AM To: ____PM Gender Preference: Girls __ Boys __ Age Preference: U___ to U____ Boys: ___ Girls: ___ All: ____ Do you need hotel accommodations? Yes __ No __ If yes, which nights? ___________________ Name of roommate preference: __________________________________________ Special requests: _____________________________________________________ Rooms are only available to ref’s working two full days(shifts)(one night), three full days(shifts)(two nights). Rooms are not available for referees traveling with a team. Returning this form does not guarantee selection to referee at the selected event. Assignments will be posted at http://gameofficials.net with additional info at http://www.edpena.net Game fees : U09-10: Ref $20 U11-12: Ref $25, AR’s $16 U13-14: Ref $28, AR’s $18 U15&up: Ref $40, AR’s $20 Ed Pena's Tournaments: USL Beach Soccer Tournament July 16 - 18, 2010 SCI Labor Day Cup Presented by Nike September 4-6, 2010 HCU Adidas Columbus Day Classic October 8 - 11, 2010 Largo Halloween Tournament October 22-24, 2010 Clearwater Thanksgiving Challenge November 27-28, 2010 IMG Cup - Boys' Invitational December 11 - 13, 2010 Region C Cup February 20-21, 2010 Region C Cup February 27-28, 2010 March Madness Shootout March 12 - 14, 2010 IMG Cup – Girls’ Invitational Tournament April 1 – 3, 2011 International Easter Tournament April 23-24, 2011 Tampa/St. Pete 3v3 Super Challenge May 15-16, 2010