e-State League

Wisconsin Youth Soccer
State League & SECL Team Registration

Complete the Wisconsin Youth Soccer State League/SECL Team Registration Form below.
After you press submit, you will receive a confirmation of your registration and additional information.
Be sure to enter a valid email address as the email address you enter will be used for all future communications.

All applications for U12-U14 Boys and U12-U19 Girls are due June 30, 2008.
Blackout dates are due at the time of application.

Payment is $150.00 payable by e-Check or Credit Card

Team Information

Club Affiliation:

Team Name:

Please Include Club Affiliation in Team Name
Example: Appleton Soccer Club Strikers

Age Group:	Gender:
	Boys Girls

Preferred Division:
Premier First
SECL SECL Level

Are you playing in the WI Youth Soccer State Cup?
(Girls U15-U18 only)
Yes No

Team Contacts

Team Manager Name:

Team Manager Address:

Team Manager City/State/Zip:

City

State

Zip

Team Manager Phone Number:

Team Manager Work Number:

Team Manager Mobile Number:

Team Manager Email Address:

Confirm Team Manager Email Address:

Coach Name:

Coach address:

Coach City/State/Zip:

City

State

Zip

Coach Phone Number:

Coach Work Number:

Coach Mobile Number:

Coach Email Address:

Confirm Coach Email Address:

Highest Level of Coaching License You Hold:

Date Current License Was Issued:
/ /

Home Field Information

Home Field Location:

Field Scheduler's Name:

Field Scheduler Phone Number:

Field Scheduler Email Address:

Confirm Field Scheduler Email:

Referee Assignor Name:

Referee Assignor Phone Number:

Referee Assignor Email:

Confirm Referee Assignor Email:

Scheduling/Blockout Dates

Please follow these guidelines:
-League Play Dates: 9/6/08 - 11/9/08
-All teams have 4 blockout dates to choose for Fall. These need to be used as 4 individual dates (Example-09/10/2008, 09/11/2008, 09/17/2008, 09/18/2008) otherwise they will not be granted. No games will be scheduled the weekend of the Wisconsin State Championships.
-State Championship Dates are: 9/13, 9/14, 9/20, 9/21/2008.
Blockout Dates (Please enter individual dates only):
Please note all dates that create schedule conflicts for your team.
Dates Must Be Entered in mm/dd/yyyy format. One Date Per Field/Entry Box ONLY.
If not in this format the dates will not be granted and will not allow your form to be submitted.

Payment Information
($150.00 fee for New Applications)

How Would You Like to Pay for this Registration? Check Credit Card

For Credit Card

Name as it Appears on Credit Card	Credit Card Type
Credit Card Number	Credit Card Expiration Date (mm/year) /
Cardholder Address	Cardholder Zip

For Check
(Please enter correct banking information. If your eCheck is returned due to invalid information,
you will be charged the program fee plus all applicable return charges and associated bank fees.)

Bank Name
Bank Routing Number (ABA Code)
Bank Account Number

Account Holder Name

I/we (above indicated) hereby acknowledge that I/we have reviewed this form and caused it to be electronically executed with the intent to be bound to the terms contained herein.

Please click ONLY ONCE on the Submit button above.
Sometimes, it takes a few seconds for the form to be processed. Thank you.