#1

Personal Information Full Name:*

#2

Date of Birth: (MM/DD/YYYY)*

#3

Address:*

#4

City:*

#5

State:*

#6

ZIP:*

#7

Phone (Home):*

#8

Phone (Cell):*

#9

Email Address:*

#10

Preferred Contact Method:*

#11

Emergency Contact Name & Phone:*

#12

Previous Umpiring Experience (List most recent first – Little League, other youth leagues, high school, etc.) *

#13

Little League Umpire Registry Member?*

#14

If yes, Registry ID or username:

#15

Highest Level Umpired: (e.g., Little League, Junior, Senior, Intermediate 50/70, other)

#16

Do you have any formal umpire training? (e.g., Little League Umpire School, local clinics, ASEP, etc.)

#17

Availability: (Check all that apply)*

#18

Preferred days/times:

#19

Have you completed a background check?*

#20

If yes, Background Check Date: Background check date

#21

Do you have current CPR/First Aid certification?*

#22

If yes, CPR/First Aid Expiration Date:

#23

T-Shirt Size - Adult:*

#24

T-Shirt Size - Size:*

#25

Any medical conditions or restrictions we should know about?

#26

Certification Agreement: I certify that the information provided is accurate. I understand that umpiring is a volunteer position and that I will be required to attend training sessions, clinics, and/or evaluations. I agree to abide by Little League rules, the league's Code of Conduct, and all safety protocols. I authorize the league to conduct a background check if needed. Please acknowledge*

#27

Signature:*

#28

Signature Date:*

#29

Parent/Guardian Signature (if under 18):

#30

Parent/Guardian Signature Date: