Existing Members Registration Form:

First name: Last name:
Gender:Date of birth:
Male
Female

New Uniform ?       $90
Yes No
Uniform size - Shirts:
Size           46 8 1012
Adult Size SM L XLXXL
Uniform size - Shorts:
Size           46 8 1012
Adult Size SM L XLXXL
Uniform size - Socks:
Size
Junior 9 - 12 12 - 4
Youth 4 - 7
Senior 7-1111-13
Shirt details :
Choose your preferred shirt colour.
White
Blue
Enter name to appear on back of shirt.
Enter number to appear on back of shirt.
Medical conditions :NoYes
If yes please detail:
Address:
Parent / Guardian:
First name:
Last name:
Email address:
Phone number:

Emergency number:

... continue top right

Kilbirnie

( 27th April 2012 - 29th June 2012 )
Ages (6 - 7)                  $200          
TOTAL = $200.00

Ages (8, 9 and 10)     $200           
TOTAL = $200.00

Ages (11, 12 and 13)   $200           
TOTAL = $200.00

Tawa

( 24th April 2012 - 26 June 2012 )

(6, 7 and 8) Tawa   $200           
TOTAL = $200.00

Ages (10, 11 and 12) Tawa    $200
TOTAL = $200.00

Total

Yes I agree to pay the full amount within 10 working days of registration, if not my placement in the Academy cannot be guaranteed. Accepted payment methods: Cash, Bank Check or Internet Banking.

Accepted payment methods
Cash, Bank Check or Internet Banking
SAMBA FUTSAL LIMITED
ASB 12-3272-0205353 (00)

Which football club do you play for, if any
How did you hear about Samba Futsal Academy?
Terms and conditions

All fees are non-refundable unless previously discussed.
These prices are subject to change in the new year. I also give permission for my child to attend the Samba Futsal Academy and for the coaches to act for me in an emergency. I also give permission for my childs photo to be used for promotional purposes. I hereby waive and release all coaches, Trust and staff from any liability for injuries sustained to my child whilst in attendance of the Samba Futsal Academy. I accept full responsibility for my child’s medical bills and associated expenses as a result of injury or illness sustained whilst in attendance at the Samba Futsal Academy. I also give consent that my child may be attended to in an emergency. Please inform us of any medical conditions.

  Yes I agree to these terms and conditions