2013 USSSA UMPIRE REGISTRATION

$75.00 includes all National & State USSSA Umpire Registration fees and clinic fees. Please include Fees with this Form Payable to: Julie Cook Send to: usssajulie@gmail.com Julie Cook 216 Highland Gretna, NE 68028

Legal Name: ______________________________________E-Mail: ____________________________________________ Address: ____________________________________________________________________________________________ City: _____________________________ ____State:_______________________________ Zip: ______________________ Telephone: ______________________________ Work: ___________________________ Cell: _______________________ Primary Sport: __________________________________ ____Registered State: ___________________________________ In Case Of an Emergency Please Contact: Name: __________________________________Phone:___________________

ACKNOWLEDGEMENT OF INDEPENDENT STATUS

1. The purpose of joining the United States Specialty Sports Association (USSSA) is to direct, officiate and promote softball games, and to also promote the game of softball in accordance Constitution of the USSSA. 2. The USSSA's main purposes are to provide softball games (tournaments) for properly sanctioned teams to participate in, and to promote the game of softball. 3. The undersigned understands and acknowledges that the USSSA is not his/her employer and therefore is not responsible for withholding federal and/or state income taxes or Social Security, etc. The undersigned is not entitled to receive Worker's Compensation coverage or unemployment insurance and that his/her relationship with the USSSA is that of an INDEPENDENT CONTRACTOR. 4. ACCIDENT & LIABILITY INSURANCE POLICIES are the sole responsibility of the undersigned. Officials that submit their USSSA Umpire Registration fee ARE provided with the USSSA Accident and Liability Insurance Policies. 5. In consideration for receiving and accepting the opportunities presented by the USSSA, the undersigned agrees to be bound by the Constitution of the USSSA, including, but not limited to, Director's and Official's conduct on and off the field, job performance, and all disciplinary procedures levied by the USSSA. I hereby acknowledge reading and ratify the ACKNOWLEDGEMENT OF INDEPENDENT STATUS.

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