presents Victoria Highlanders FC Academy

Step 1. Player contact information

*First Name: *Last Name: *Gender: M F *Address: Address Line 2: *City: *Province: *Postal Code:

*Evening Phone: Mobile Phone: *Player's Birth Date: mm 1 2 3 4 5 6 7 8 9 10 11 12 dd 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 yyyy 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 *Email address: *Parent/Guardian: *Emergency Phone:

Step 2. Tryout/personal information
* What program are you registering for? Academy/Prospects 2011-2012 Hold down Ctrl for multiple selection
* Preferred position:	-- Choose a Position -- Forward Midfielder Defender Goalkeeper
Were you referred to this program by a current Highlanders player? If yes, enter full name of player:

Step 3. Additional information
* Club Team:
Level (Metro, Gold, Silver, Bronze):
* Shirt Size:	-- select size -- youth small youth medium youth large youth x-large small medium large x-large

Payment Options:
Call the office at 250-590-8432 to pay by credit card

or

Cheques are payable to Victoria Highlanders FC
Attn: Highlanders FC Academy

Mailing Address:
PO Box 39026
RPO James Bay
Victoria, BC
V8V 4X8