Form

Youth & Senior Futsal State Team Trial Registration Form

First Name*

Surname*

Date of Birth*

Month Day Year

What will your age be at 31/12/2009?*

Gender*

Male Female

Email (All correspondence will be sent directly to this address)*

Re-type email address*

Address*

Suburb*

Postcode*

Phone Number (BH)*

Mobile*

Is this the first time you've trialled for a Futsal State team?*

Yes No

What position are you trialling for?*

Goalkeeper Outfield Player

Please specify if you are/were in any of the following programs*

Futsal State team (Jan 2009 Tour) Summer League W-League NTC Vikings Futsal None of the above

Do you play in a Futsal competition?

Yes No

If Yes, please specify what competition you play in?

What age category do you play in?

Do you play for an outdoor Football Club?*

Yes No

If Yes, please specify what Club you play for?

What age category do you play in?