APPLICATION FORM FOR REFEREES/TECHNICAL OFFICIALS FOR THE

2016 LIFESAVING WORLD CHAMPIONSHIPS TO BE HELD FROM 1ST SEPTEMBER, 2016 TO 18TH SEPTEMBER, 2016 IN EINDHOVEN & NOORDWIJK-AAN-ZEE, THE NETHERLANDS

n.b. - Please print or type –

NAME:

Given (First or called name): Family (Last or surname):

DATE OF BIRTH: AGE:

NATIONAL FEDERATION, STATE/PROVINCE/ BRANCH /ZONE AND CLUB:

Federation
State /Province/Branch/Zone
Club

E-MAIL This address will be used in all future correspondence. If you do not have e-mail address – any other e-mail address that can be used for correspondence will suffice:

QUALIFICATIONS: Date qualified as a Referee/Technical Official, the Federation/Authority who issued the qualification and any further qualifications and levels obtained as well as any enhancement to the qualification if applicable:

Date / Qualification / Federation/Authority / Level

LANGUAGE PROFICIENCY: Please indicate in what languages you can communicate in – basically your speaking ability:

LANGUAGE / Speaking Ability Only (YES)
English
French
Spanish
Netherlands
German
Other:

APPLICATION FOR POOL AND SERC CHAMPIONSHIPS

Nominate which Pool and SERC Championships you would like to officiate in. Note that some Championships are run simultaneously – refer to the attached programme. However, if you would like to apply for a position that occurs simultaneously, please rank the positions applied for.

lifesaving world Championship / DATES / CHAMPIONSHIPS APPLIED FOR
National Open Teams Pool Championship and National Youth Teams Pool Championship / 7th, 8th, 10th & 11th September
InterClub Open Teams Pool Championship and InterClub Youth Teams Pool Championship / 13th, 14th, 16th, 17th & 18th September
Masters Pool Championship / 2nd & 3rd September
National Open Teams Simulated Emergency Response Competition Championships (SERC) and National Youth Teams SERC Championships / 6th & 10th September
InterClub Open Teams SERC Championships and InterClub Youth Teams SERC Championships / 13th & 16th September

Positions you would like to officiate in, list in priority order (1, 2, 3, 4, 5 – please only list 5 options) in each event, 1 being the most preferred position and 5 the least preferred position. Note you are not required to complete each and every block – only 5 or less.

Position

/ Rank (5 only)
Jury of Appeal
Event Director
Commentator
Starter
Competitors Liaison
Presentations
Lane Judge
Turn Judge
Finish Judge
Place Judge
Marshall/ Security
Chief Timekeeper
Time Keeper
Equipment/ Gear Manager
Risk Assessor
Safety Officer
Emergency Services Officer
Other: Specify

POOL EXPERIENCE: INTERNATIONAL EVENTS: Dates and events and position at all International Pool Events you have officiated in the last 2 years.

For example:

Date / International Event / Position
July 2013
August, 2014 / World Games, Cali, Colombia
Junior European Championships, Oostende, Belgium / Chief Referee
Deputy Chief Referee
Date / International Event / Position

POOL EXPERIENCE: NATIONAL EVENTS: Dates and events and position at all National Pool Events you have officiated in the last 2 years.

For example:

Date / National Event / Position
March, 2014
April 2014 / South African National Pool Lifesaving Championships
Royal Lifesaving United Kingdom Championships / Deputy Referee
Event Director
Date / National Event / Position

APPLICATION FOR OCEAN & BEACH, IRB AND SURF BOAT CHAMPIONSHIPS

Nominate which Ocean & Beach, IRB and Surf Boat Championships you would like to officiate in. Please note that some events occur simultaneously – refer to the attached programme.

World Championship / DATES / CHAMPIONSHIPS APPLIED FOR
National Open Teams Ocean and Beach Championship and National Youth Teams Ocean and Beach Championship / 7th, 8th, 10th & 11th September
InterClub Open Teams Ocean and Beach Championship and InterClub Youth Teams Ocean and Beach Championship / 12th, 13th, 14th, 16th & 17th September
Masters Ocean and Beach Championship / 5th & 6th September
Surf Boat Championship (including Masters) / 8th & 9th September
IRB Championship / 10th & 11th September

Positions you would like to officiate in, please list in priority order (1, 2, 3, 4, 5 – please only list 5 options) which position you wish to be considered for in each event, 1 being the most preferred position and 5 the least preferred position. Note you are not required to complete each and every block – only 5 or less.

Position

/ Rank (5 only) /
Jury of Appeal
Commentator
Presentations
Sectional Referee
Chief Judge
Judge
Judge in Boat
Course Judge
Starter
Check Starter
Marshall
Check Marshall
Competitors Liaison
Computer Result Recorder
Recorder
Scrutineer
Risk Assessor
Safety Officer
Emergency Services Officer
Other: Specify

EXPERIENCE: INTERNATIONAL EVENTS: Dates and events and position at all International Ocean and Beach Events you have officiated in the last 2 years – also indicate section you refereed in.

For example:

Date / International Event / Position / Section
September 2015
August, 2014 / International Surf Rescue Challenge; Australia
Junior European Open Water Championships, Oostende, Belgium / Sectional Referee
Sectional Referee / Ocean
Beach
Date / International Event / Position / Section

EXPERIENCE: NATIONAL EVENTS: Dates and events and position at all National Events you have officiated in the last year – also indicate section you refereed in.

For example:

Date / National Event / Position / Section
March, 2015
April 2015 / South African National Surf Lifesaving Championships
Australian Surf Championships / Starter
Sectional Referee / Beach Events
Ocean Events
Date / National Event / Position / Section

Please complete the following declaration:

Name (enter in Block Capitals): ______

I apply to be considered for appointment to a Referee/ Technical Official at 2016 Lifesaving World Championships. I am currently a member of

______(Federation)

I am in good standing with the above mentioned Federation. (The ILS Sport Commission will seek endorsement from your Federation before any appointment is confirmed).

I understand that I or my Federation will be responsible for all travelling and accommodation expenses and further that no claim for such expenses will be made by me to the 2016 Lifesaving World Championships Local Organising Committee, the Royal Dutch Lifesaving Federation (Reddingsbrigade Nederland/ KNBRD) or ILS Sport Commission or ILS.

I hereby undertake to make myself available for the full duration of the Championship (i.e. Youth and Open) to which I am appointed as a Referee/Technical Official including the pre and or after Championship Briefings as required by the Chief Referee, the Chairman of the ILS Sports Commission or ILS Sports Commission.

Signed: …………………………………………………………………………………

Date: ………………………………………………………………………………..

Application on the form set out above should be sent to the Secretary: ILS Sports Commission to arrive not later than the 1st September, 2015 by one of the following methods:

·  E-mail:

Please return in either a PDF (as one document) or in MS Word format.

·  Mail: Secretary: ILS Sports Commission

P O Box 572

UNDERBERG

3257

SOUTH AFRICA

·  Fax: +27 (0)31312 5612 Attention: Jelle Meintsma

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