__Byron-Bergen Central School District Athletic Department
JV/Varsity or JV only - Swimming & Diving Voucher; Ver. 1.0
2021-2022

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 Starting Time: ___________

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

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

SWIMMING (COMBINATION – JV/Varsity) with or w/o DIVING for a 1 ½ hr. event:

JV/Varsity	JV only REFEREE: $105.00                 $84.60 STARTER: $103.00                 $83.00
JUDGE: $102.00	$82.20

* - After 1½ hrs. an additional fee is paid for each additional ¼ hr. at the rate noted below:

JV/Varsity REFEREE: $8.50* STARTER: $8.25*
JUDGE: $8.00*

Reimbursement Requested:

JV only $6.50*
$6.25* $6.00*

Base fee: ______________

*If the meet extended beyond 1½ hrs.: # of ¼ hrs. _______ @ _______ = ______________

Total fee requested: = ______________

**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. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Approved: _________________________________ Director of Athletics

Approved: _________________________________ District Office

Date: __________________

Date: __________________

df (7/8/21); ver. 1.0