Referee's Send Off Report Form


  1. Please complete the following Referee's Send Off Report Form for any player or coach that you sent off in your game.
  2. Submit one form per send off.
  3. When you submit the form, an email will be sent to you with an attachment of the PDF of the CYSAN Referee Send Off Report pre-filled. Print this report, and mail it together with the sent off person's card to the appropriate authority as indicated in the email you will receive.
  4. The "appropriate authority" for the competition is listed in the sidebar to the right.

Alternatively, you may download and fill out the PDF of this web form, but you will not be able to save the form with your data. Download the PDF of the CYSA-N Referee Send Off Report.

Game Information
Game Date // required
Use date format of 4/24/2014 for April 24, 2014
Game Time :  required
Use 12-hour time format
Field  required
City  required
League required
Age Group  required
Home Team  required
Visiting Team  required
Send Off Information
Name of Individual  required
Send Off Time  required
Example: "65" means the 20th minute in the second half of a game with 45-minute halves.
Registration Number  required
Jersey Number  required
Team  required
Individual Sent Off Was required
Send Off Reason required
Serious Foul Play
Violent Conduct
Spit At Opponent Or Any Other Person
Denied Obvious Goal-Scoring Opportunity to Opponent Moving Towards Goal by Offense Punishable with Free Kick or Penalty Kick
Denied Obvious Goal-Scoring Opportunity by Deliberately Handling Ball
Received Second Caution in Same Game
Offensive, Insulting or Abusive Language
The following are required when "Send Off Reason" is "Offensive, Insulting or Abusive Language"
Specific Language Or Gesture

Directed At
Explanation required
Referee Information
Referee Name  required
Referee Telephone  required
Referee Email  required
AR1 Name  required
AR1 Telephone
AR1 Email
AR2 Name  required
AR2 Telephone
AR2 Email

After submitting your information,
an email will be sent to you
with further instructions.

District 6

Web Site by Steve Piercy