Virginia State Cup
2005 FUTSAL® State Cup
January 29 & 30 2005
Youth Team Registration Form

FIFA
World Wide

CONCACAF
Regional

U.S. Soccer Federation
National Federation

U.S. Futsal® Federation
National Association

USFF Region I
Regional Association

Virginia Futsal Association

Team Name:

Contact Name:

Contact Is:

___ Coach ___ Assistant Coach___ Manager

Address:

City, State, Zip:

Cell Phone #s:

Home Phone #s:

Work Phone #s:

E-Mail:

Season

Age/Division

League

USYSA 2003:

Fall

Spring

USFF 2003:

Summer

Winter

Bracket:

___ Boys ___ Girls

Group:

___ U-10___ U-12___ U-14___ U-16___ U-19

Fees:

Mail Information to: cup@vafutsal.com

___ $195

• Includes:
• 3 Game Minimum
• In any division where a team is not scheduled to play a minimum of three games, $40.00 per game not scheduled will be deducted from the $195.00 registration fee.
• Two Referees for all games

• Requires:
• Information on this form to be eMailed to cup@vafutsal.com
• Printed form and $195 fee brought to State Cup
• Online Registration of all Players and Coaches with USFF and the Virginia State FUTSAL® Association

Signature

Date

Printed Name