/*--- Avanquest WebEasy Custom Script ---*/

<!-- Begin Freedback Form --> 
<!-- DO NOT EDIT YOUR FORM HERE, PLEASE LOG IN AND EDIT AT FREEDBACK.COM --> 
<form enctype="multipart/form-data" method="post" action="http://www.freedback.com/mail.php" accept-charset="UTF-8"> 
	<div> 
		<input type="hidden" name="acctid" id="acctid" value="805yd1fnc8m0180i" /> 
		<input type="hidden" name="formid" id="formid" value="410288" /> 
		<input type="hidden" name="required_vars" id="required_vars" value="name,field-8c709d28184cf40,email,field-9a53b2807b6cbfc,field-121df7c3f219e0a,field-f5734bf6da15f72,field-8a77dbede01fd6b,field-06e6bca13998ef0,field-fa086bfee3baaec,field-d4fddc9992ba02e,field-98ebcf575d70e87,field-2c580062abc6470,field-a1c8e538e72934a,field-7c50febfd82979f" /> 
	</div> 
	<table cellspacing="5" cellpadding="5" border="0"> 
		<tr> 
			<td valign="top"> 
				<strong>Player Name:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="name" id="name" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Address:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-8c709d28184cf40" id="field-8c709d28184cf40" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Email Address:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="email" id="email" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Home Phone:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-9a53b2807b6cbfc" id="field-9a53b2807b6cbfc" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Second Phone:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-468ab33f2235287" id="field-468ab33f2235287" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Parent Name:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-121df7c3f219e0a" id="field-121df7c3f219e0a" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Parent Name:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-20cf5369b7cd60d" id="field-20cf5369b7cd60d" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>D.O.B.:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-f5734bf6da15f72" id="field-f5734bf6da15f72" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Age:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-8a77dbede01fd6b" id="field-8a77dbede01fd6b" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Gender:</strong> 
			</td> 
			<td valign="top"> 
				<select name="field-06e6bca13998ef0" id="field-06e6bca13998ef0"> 
					<option value="Female">Female</option> 
					<option value="Male">Male</option> 
				</select> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>School:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-fa086bfee3baaec" id="field-fa086bfee3baaec" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Grade:</strong> 
			</td> 
			<td valign="top"> 
				<select name="field-d4fddc9992ba02e" id="field-d4fddc9992ba02e"> 
					<option value="4th">4th</option> 
					<option value="5th">5th</option> 
					<option value="6th">6th</option> 
					<option value="7th">7th</option> 
					<option value="8th">8th</option> 
					<option value="9th">9th</option> 
					<option value="10th">10th</option> 
					<option value="11th">11th</option> 
					<option value="12th">12th</option> 
				</select> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Name of team last played on:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-98ebcf575d70e87" id="field-98ebcf575d70e87" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Number of years played soccer:</strong> 
			</td> 
			<td valign="top"> 
				<input type="text" name="field-2c580062abc6470" id="field-2c580062abc6470" size="40" value="" /> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Team requested to play on:</strong> 
			</td> 
			<td valign="top"> 
				<select name="field-a1c8e538e72934a" id="field-a1c8e538e72934a"> 
					<option value="U11">U11</option> 
					<option value="U12">U12</option> 
					<option value="U13">U13</option>  
					<option value="U14">U14</option> 
					<option value="U16">U16</option> 
					<option value="U18">U18</option> 
				</select> 
				 
			</td> 
		</tr> 
		<tr> 
			<td valign="top"> 
				<strong>Are you requesting to play:</strong> 
			</td> 
			<td valign="top"> 
				<input type="checkbox" name="field-7c50febfd82979f[]" id="field-7c50febfd82979f_0" value="Spring" /> Spring<br/> 
				<input type="checkbox" name="field-7c50febfd82979f[]" id="field-7c50febfd82979f_1" value="Fall" /> Fall<br/> 
				<input type="checkbox" name="field-7c50febfd82979f[]" id="field-7c50febfd82979f_2" value="Both" /> Both<br/> 
				 
			</td> 
		</tr> 
		<tr> 
			<td colspan="2" align="center"> 
				<input type="submit" value=" Submit Form " /> 
			</td> 
		</tr> 
	</table> 
</form> 
<br><center><font face="Arial, Helvetica" size="1"><b> 
<a href="http://www.freedback.com">form mail</a> 
</b></font></center> 
<!-- End Freedback Form --> 


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