2017 Induction Night VIP - Dynamic Footy Skills

Name*
First Last
Address*
Street Address City ZIP / Postal Code
Date of Birth*
Select which player registration package you will pursue*
Would you be kind enough to provide more details as why this year's Elite Camp is not for you.
Name of Parent / Guardian*
Parent / Guardian Phone No. (Mobile)*
Parent / Guardian email address*
Player email address (Leave blank if none)
Player phone No. (Leave blank if none)
2018 Local Club*
Any medical conditions / allergies*
I have read and understand the information outlined below*
1) To become eligible for selection a $200 deposit will be required. 2) You will be issued an invoice for the deposit, upon submission of this form 3) If you are not selected but wish to continue in the training squad, you will not be reimbursed the $200 4) If you are NOT selected in the playing squad and do NOT wish to continue with the training squad, a full refund of your $200 will be issued. 5) The $200 deposit needs to be paid before Monday 16th April
- YES
Total
ONLY payable should you be selected in the representative team
$ 0.00