Existing members register HERE →
If you are a new member, please fill in the form below.

First name: Last name:
Gender:Date of birth:
Male
Female
Uniform size - Shirts:
Size           46 8 1012
Adult Size SM L XLXXL
Uniform size - Shorts:
Size           46 8 1012
Adult Size SM L XLXXL
Uniform size - Socks:
Size
Junior 9 - 12 12 - 4
Youth 4 - 7
Senior 7-1111-13
Shirt details :
Choose your preferred shirt colour.
White
Blue
Enter name to appear on back of shirt.
Enter number to appear on back of shirt.
Medical conditions :NoYes
If yes please detail:
Address:
Parent / Guardian:
First name:
Last name:
Email address:
Phone number:

Emergency number:

... continue top right

New Member        $90

KILBIRNIE

( Thursdays: 19 October - 21 December 2017 )
Ages 10, 11 and 12    $200 + $90   
TOTAL = $290.00

Ages 13 to 16    $200 + $90   
TOTAL = $290.00

KILBIRNIE

( Fridays: 20 October - 22 December 2017 )
Ages (6-7)      $200 + $90   
TOTAL = $290.00

Ages (8 - 9 )     $200 + $90    
TOTAL = $290.00

Ages (10 - 11)   $200 + $90   
TOTAL = $290.00

Ages (12 to 15)   $200 + $90   
TOTAL = $290.00

Ages (16 to 19 )   $200 + $90   
TOTAL = $290.00

TAWA

( Tuesdays: 17 October - 19 December 2017)
Ages (8 to 11) Tawa   $200 + $90
   TOTAL = $290.00

Ages (12 to 15) Tawa   $200 + $90
   TOTAL = $290.00

LOWER HUTT  

( Wednesdays: 18 October - 20 December 2017 )
Ages (9, 10 and 11) Lower Hutt  
$200 + $90
   TOTAL = $290.00

Ages (12 to 15 ) Lower Hutt  
$200 + $90
   TOTAL = $290.00

Ages (16 to 19) Lower Hutt  
$200 + $90
   TOTAL = $290.00


Total

Yes I agree to pay the full amount within 10 working days of registration, if not my placement in the Academy cannot be guaranteed. Accepted payment methods: Cash, Bank Check or Internet Banking.

Accepted payment methods
Cash, Bank Check or Internet Banking
SAMBA FUTSAL 2014 LIMITED
ASB 12-3141-0389949-00

Which football club do you play for, if any
How did you hear about Samba Futsal Academy?
Terms and conditions

All fees are non-refundable unless previously discussed.
These prices are subject to change in the new year. I also give permission for my child to attend the Samba Futsal Academy and for the coaches to act for me in an emergency. I also give permission for my childs photo to be used for promotional purposes. I hereby waive and release all coaches, Trust and staff from any liability for injuries sustained to my child whilst in attendance of the Samba Futsal Academy. I accept full responsibility for my child?s medical bills and associated expenses as a result of injury or illness sustained whilst in attendance at the Samba Futsal Academy. I also give consent that my child may be attended to in an emergency. Please inform us of any medical conditions.

  Yes I agree to these terms and conditions