__Byron-Bergen Central School District Athletic Department
Modified Swimming Voucher 2021-2022 Ver. 1.0

Name:______________________________________	Phone number: _______________________ (Please Print)

Address: _____________________________________________________________________________ Number	Street	City	Zip code

Social Security #: __________-________-___________ (Must be filled in, at least the first time, to each district, to be processed)

Home team: _________________; Opponent: ___________________; Published Start Time: __________

Are you employed by this district in any other capacity? Yes _______; No _______ Assignment:	Modified Swim Official	Meet Date: ______________________

Contest (actual) start time: ______________; Contest end time (if after 1 ½ hrs.): _______________

SWIMMING fees (with or w/o Diving) for a 1 ½ hr. event:

REFEREE: $74.40 STARTER: $73.00 JUDGE: $72.30

* - After 1 ½ hrs. an additional fee is paid for each additional ¼ hr. at the rate noted below*

REFEREE: $4.50* STARTER: $4.25* JUDGE: $4.00*

Reimbursement Requested:	Base fee: ______________

*If the meet extended beyond 1 ½ hrs.: # of ¼ hrs. _______ @ _______ = ______________

Total fee requested: =	______________

Officials signature: ________________________________	Date: __________________

*Officials please note: By officiating this contest, and signing this voucher, you are indicating that you have been properly finger printed and background checked and that you have been found employable by NYSED standards in NYS Public Schools.
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Approved: _________________________________ Director of Athletics
Approved: _________________________________ District Office

Date: __________________

Date: __________________

df (7/8/2021), ver. 1.0