_Byron-Bergen Central School District Athletic Department
Modified Wrestling Voucher 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)

Are You employed by this district in any other capacity? Yes _______; No _______

Assignment: __Modified Wrestling Official

Event:

Sport: _____ Modified Wrestling_____	Contest Date: ______________________

Opponent(s): ____________________________________________________________________

Starting Time: ___________ Meet site: __________________________

Modified meet fee: = $74.40

Extra modified bouts, if any: ______ X $4.95 = ___________

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.
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Approved: _________________________________ Director of Athletics

Approved: _________________________________ District Office

Date: _______________

Date: _______________

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