Byron-Bergen Central School District Volleyball Voucher
2022-2023 (Version: 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)

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

Assignment: Volleyball Official

Home Team: ______________________	Contest Date: ___________________

Opponent: ________________________ Starting Time: ___________ Place: ________________

Level:	Varsity	JV	Modified	Boys	Girls

Check one (1) below:

JV/Varsity combo: 1^st referee (Var. contest) $181.00 (Var. [3 of 5]; JV [3 of 3])

Varsity match only (3 of 5) 1^st referee: $103.00

JV match only (3 of 3): $78.00

JV/Varsity combo: 2^nd referee (Var. contest) $167.00 (Var. [3 of 5]; JV [3 of 3])

Varsity match only (3 of 5) 2^nd referee: $89.00

Modified (3 of 3): $69.00

Modified (5 of 5): $92.70

Modified (6 of 6): $93.60

(3 of 5) Line Judge - $66.00;	(3 of 5) Scorer/Libero - $53.00

The tournament pool rate is: 2 of 3 and 3 of 3 tournament play - $21/game Varsity and $17/game JV.

Number of tournament games: ________ at $21.00; ________ at $17.00 = ________________

I worked alone; 1½ fee = ________________

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

df (7/21/2022)

Date: ________________

Date: ________________