Expression of Interest to become a referee

This survey is to register your interest in becoming a Referee, it does not guarantee you a place in the course.

You must be 14 years or older to become a referee.

The courses run course runs for 4 weeks in line with rounds 1- 4 of the Junior Domestic season. The course generally runs term 2 and 4 and the cost of the course is $100.00 payable before the commencment of session 1.

There will be try-out sessions organised prior to the course starting to determine suitability. Basketball training is not an excuse to not attend your taining sessions and there will be no make up sessions.
Expression of Interest to become a referee
First Name *
Surname *
Gender *

Male Female
Date of Birth *

Day Month Year
Date
Address *
Suburb *
Post Code *
Mobile Phone Number *
Email *

Confirmation Email example@example.com
Do you play or coach Junior Domestic Basketball at Keilor? *

Yes No
Who do you play for?

Aberfeldie Jets Avondale Raiders Calder Bears Caroline Springs Blue Devils Hornets Basketball Club Keilor Village Overnewton Fire St. Bernards St Christophers Saints Sydenham Panthers Taylors Lakes Western Eagles
Emergency Contact
Name *

First Name Last Name
Relationship *
Phone Number *
Medical Information
Do you have asthma, hay, fever, or coughing spells. YES/NO - please specify *
Do you have any allergies? YES/NO - Please Specify *
Do you have chronic illness, or see a doctor regularly for any particular reason? If so please provide details. *
Why do you want to become a referee? *
How did you hear about becoming a referee *

Keilor Basketball (KBA) Website Keilor Basketball (KBA) Social Media VBRA Keilor Website VBRA Keilor social media Junior Domestic Club Another Referee Enquired via the Supervisor at Keilor Enquired via KBA Office I just decided I wanted to become referee
Referee Shirt Size *

Small Medium Large X Large 2X Large
Should be Empty:

Expression of Interest to become a referee

Emergency Contact

Medical Information