Player Detail Form Name * First Name Last Name Email * Phone * Country (###) ### #### US Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Position(s) * Instagram Username * Twitter Username * Date of Birth * Month-Date-Year Format Place of Birth * Country of Citizenship * Do you have primary health insurance? * Who is your primary insurance through? * 1. Insurance Company 2. Who are you insured through? (School, Family, Yourself, etc) Player History Have you... * Select as many that applies to your playing history Played Professionally Played Internationally None of the Above FIFA ID (If you've received one) Current Team Current Team Name * Current Team Location * Current Team League * Current Team Federation * Current Team: Date of the Last Match Played for this team * MM DD YYYY Previous Team Previous Team Name * Previous Team Location * Previous Team League * Previous Team Federation * Previous Team: Date of the Last Match Played for this team * MM DD YYYY Thank you!
