Recreation Officials Information

ABOUT RECREATION OFFICIALS

RECREATION OFFICIALS REGISTRATION

First Name

Middle Name

Last Name

Username

Password

Confirm Password

There are no public membership products available to purchase at this time. Please login for other possible options.

Passport Style Photo of your Noggin

Select Image (.png, .jpg, .jpeg, .gif)

Member Address

Country

Address

Phone Number

Mobile Number

Emergency Contact Name

Emergency Contact Telephone

Emergency Contact Relationship

WORKING WITH CHILDREN CHECK

Working with Children/Police Check

WWCC Number

WWCC Expiry Dare

Image of WWCC Card

Select Image (.png, .jpg, .jpeg, .gif)

MEDICAL INFORMATION

Blood Group

Date of last Tetanus

Have you ever been diagnosed as having and/or had treatment for: (Please Tick)

Allergies

Yes

Severe headache,head injury, epilepsy, seizure or loss of consciousness

Yes

A psychiatric or psychological illness

Yes

Heart or lung disease, including infection or blood vessel disease

Yes

Hypertension, coronary bypass, angioplasty or other surgical procedure

Yes

Cancer, diabetes, kidney, liver or any associated surgical procedures

Yes

Thyroid, gastrointestinal or any associated surgical procedures

Yes

Blood pressure disorders or any associated surgical procedures

Yes

Any other significant illness, injury or surgery not already noted

Yes

Have you taken medications, including self-medication or alternative therapies

Yes

Do you have any hearing impairment or loss

Yes

Do you suffer from any hearing disorder including tinnitus

Yes

Is your eyesight normal in both eyes for distance vision

Yes

When did you last have a medical examination

OFFICIALS INFORMATION (Include disciplines & roles)

Have you previously held an Officials Licence

Yes

Details of your officiating history by DISCIPLINE (eg Speedway)

Details of your officiating history by EVENT (eg Secretary)

REFERENCES (Details of 2 senior officials who could provide referencing to AMA)

Reference 1 Name to recommend you

Reference 1 mobile

Reference 1 officiating roles

Reference 2 Name to recommend you

Reference 1 email

Reference 2 mobile

Reference 2 officiating roles

Reference 2 email

SUPPORTING DOCUMENTS

Provide any supporting documents you may have to help with your applicatication

I have read, understand and will abide by the terms and conditions of AMA Racer

I Agree