2023 Canadian Championship Umpire Nomination Form

Championship Nominated For: (Required)

First Name (Required)

Last Name (Required)

Email (Required)

Phone (Required)

Address: (Required)

City (Required)

Province/Territory (Required)

Postal Code (Optional)

Gender Identity (Required)

Male

Female

Transgender Male

Transgender Female

Non-Binary or Not listed

Size (jacket/shirt) (Required)

S

M

L

XL

Smoker/non-smoker (Required)

Certification Level and Year Attained (Required)

YesNo

Seeking Level 4 Practical

YesNo

National Umpire Exam - successfully completed for 2022.

List previous Championships (if any) (Optional)

Medical Issues (explain) (Required)

YesNo

The umpire is nominated at U19 and above and has completed the fitness assessments.

Fitness testing was observed and verified by? (Optional)

YesNo

Plate Squat Test Completed

27 Metre dash (time in secs - to tenth of a sec) (Optional)

Agility “T” Test (time in secs - to tenth of a sec) (Optional)

1000 Metre Run (minutes: seconds) (Optional)

Form completed by (PT UIC) (Required)