e-State League

Wisconsin Youth Soccer
State League & SECL Team Registration

Now Accepting applications for:
U12-U14 Boys State League (First Division & Premier)
U12-U19 Girls State League (First Division & Premier)
U11-U14 South East Classic Girls League.

Applications are due:
U11-U14 SECL and U12-U14 Girls State League - July 3rd, 2009
U15-U18 SECL and U15-U18 Girls State League - July 10th, 2009
Blackout dates are due at the time of application.

Payment is $200.00 payable by e-Check or Credit Card for U11-U14 teams

Payment is $175.00 payable by e-Check or Credit Card for U15-U19 teams

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?
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:
-All teams are allowed 6 blackout dates for fall league play. These need to be used as 6 individual dates (example- 09/19/2009, 9/20/2009).

No games will be scheduled the weekend of Labor Day and the first weekend of the Wisconsin State Championships (September 19th and 20th).

-League Play dates: August 29th- November 7th
-State Championship Dates are: September 19th, 20th, 26th, September 27th (Semi-finals). Only the first weekend will be blocked out for league games as no league games will be scheduled.

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
($200.00 or $175.00 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.