Region * Select Region EAST Region MIDWEST Region SOUTH Region WEST Region

State *

Club Name/Location *

Club Type Select Club Type University Club Community Club Professional Club School Club After School Lunch Program Other

Number of Members

Club Address

Club Email

Club Contact Number

Club Website (if applicable)

Grade/Level

Equipment

e.g., Tornado (2), Shelti (1), etc.

Full Name

Representative Email

Representative Phone Number

Role in the Club Select Role President Coach Manager Facilitator Member Other

Select all that apply:

Club Logo

Upload your club logo (JPEG, PNG, or GIF).

Club Registration Certificate (Optional)

Upload your club registration certificate (PDF, JPEG, or PNG).

I confirm that our club abides by the rules and regulations of the fooseball club. *