Northland FC 2022 Youth Selection Process Registration

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* 1. Players Name

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* 2. Players Gender

Male

Female

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* 3. Players DOB

Date / Time

Date

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* 4. Players Current School

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* 5. Is your child a New Zealand Citizen?

Yes

No

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* 6. Which club team (e.g Tikipunga AFC) is your child registered with in 2021?

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* 7. Parent/ Guardian Contact 1

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 8. Parent/Guardian Contact 2

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 9. Please Provide 1 Sporting Reference (Sports Teacher, Club Coach etc.)

Note: This person may be contacted to discuss your registration

Name

Email Address

Phone Number