Club Registration Fee Refund Request

1
Club Name* This field is required.
2
Submitted By * This field is required.
First Name
Last Name
3
Email* This field is required.
example@example.com
4
If player is claiming insurance for injury through Gow Gates the national player insurance provider they will need to remain active and paid of the FA/FV fee.

Clubs can lodge an insurance claim on behalf of the player via the website;
Gow Gates Football Insurance
5
To be eligible for a player refund the player must first be de-registered.
Please action the players de-registration prior to submission.
6
Players who have appeared on a match record in competition are not eligable for a registration fee refund.
7
Reason for request* This field is required.
Player leaving sport prior to season commencement
Injured player prior to season commencement
Player has been charged twice
Incorrect registration product chosen
8
Has the player De-Registered or been Declined on Play Football* This field is required.
Yes
No
9
Has the player appeared on a Match Record (Team Sheet) for the current season * This field is required.
Yes
No
10
Player Details
11
Players Name* This field is required.
First Name
Last Name
12
Player FFA ID Number* This field is required.
13
Player Date of Birth* This field is required.
Date
Month
Day
Year
14
I agree that all of the above information is true and correct* This field is required.
I Agree
Should be Empty: