ASA Umpire Registration Verification

I hereby certify that I will be an ASA registered umpire and agree to participate in the designated ASA event as an ASA Umpire.

I understand that there are certain risks of injury inherent in performing the duties of a softball umpire, as well as in traveling and other related activities incidental to my participation, and I am willing to assume these risks. I hereby certify that I am capable of participating in the designated ASA event and that I am healthy and have no physical or mental disabilities or infirmities that would restrict full participation in these activities, except as listed below. All fields must be filled in - no exceptions.

Name:         

Address:

City:     State:      Zip:

Emergency Contact Person:

Daytime Phone for Emergency Contact Person:

Evening Phone for Emergency Contact Person:

List any physical limitations in the box below (if none, state none):

I acknowledge that I be a required Amateur Softball Association umpire for the Rebel Spring Games program I have been accepted. Failure to register will result in my services being terminated.    No Yes

Date/Acknowledgment: