Channel Coast Officials Association
On-Line Membership Application Form

Directions for filling out the on-line application:

Please enter the required information on the fields below.

Specify the school nearest to your home for accurate mileage fees computations

For all phone numbers, please enter the information using this format: xxx-xxx-xxxx

From the list of sports below, select those sports that you would like to get more information regarding membership and training. The per game fees paid for officials for each sport is listed next to each sport.

Select Sports
Please visit the Football site on the previous page	Please visit the Volleyball site on the previous page	Cross Country/Track & Field ($56-$98)
Please visit the Basketball site on the previous page	Soccer ($48-$93)	Water Polo ($48-$101)/Swimming ($54-$151)
Please visit the Baseball site on the previous page	Softball ($51-$60)	Wrestling ($20-$98)

Personal Information
First Name		Middle Name			Last Name
Address
City		State		Zip
Email
		School Nearest Home	AgouraBesant HillBishop DiegoBuenaCalabasasCamarilloCarpinteriaCateChannel IslandsCornerstoneDos PueblosDunnFillmoreGrace BrethrenHillcrestHuenemeLa ReinaLaguna BlancaMalibuMidlandMoorparkNew RoadsNewbury ParkNewbury Park AdventistNordhoffOak GroveOak ParkOaks ChristianOjai ValleyOxnardPacificaRio MesaRoyalSan MarcosSanta BarbaraSanta ClaraSanta PaulaSimi ValleySt. BonaventureThacherThousand OaksVenturaVentura County ChristianViewpointVillanovaWestlake
		School Nearest Work	AgouraBesant HillBishop DiegoBuenaCalabasasCamarilloCarpinteriaCateChannel IslandsCornerstoneDos PueblosDunnFillmoreGrace BrethrenHillcrestHuenemeLa ReinaLaguna BlancaMalibuMidlandMoorparkNew RoadsNewbury ParkNewbury Park AdventistNordhoffOak GroveOak ParkOaks ChristianOjai ValleyOxnardPacificaRio MesaRoyalSan MarcosSanta BarbaraSanta ClaraSanta PaulaSimi ValleySt. BonaventureThacherThousand OaksVenturaVentura County ChristianViewpointVillanovaWestlake
Home	(xxx-xxx-xxxx)	Work	(xxx-xxx-xxxx)
Pager	(xxx-xxx-xxxx)	Cell	(xxx-xxx-xxxx)
Fax	(xxx-xxx-xxxx)
Have you ever been convicted of a crime? Yes No
If yes, please explain

Experience
Level	Experience Level	Assignor	Phone Number (xxx-xxx-xxxx)
College?	None 1-5 Years 6-10 Years 10+ Years
High School?	None 1-5 Years 6-10 Years 10+ Years
Youth?	None 1-5 Years 6-10 Years 10+ Years
Comments

Last Unit or Organization Information
Unit/Organization Name:
Assignors Name		Phone Number (xxx-xxx-xxxx)
Instructors Name		Phone Number (xxx-xxx-xxxx)
Reason For Leaving