New Futsal Provider/Centre Affiliation Form

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INTRODUCTION

This New Futsal Provider Affiliation Application Form must be completed in order for Football Victoria (FV) to approve affiliated FV Futsal providers, competitions, events and tournaments.

Please note that completion of this form does not guarantee affiliation and FV may decline an application at any time.

This New Futsal Affiliation Application Form contains the following sections:

Futsal Provider Overview
Futsal Provider Background
Futsal Provider Vision
Budget Development
Provisional Team Entries
Communications & Media
Additional Information

Approval of your application is conditional on you providing your ABN/ACN to FV and paying an annual affiliation fee of $250.00 ex GST via invoice within 7 days of approval.

Once your application has been approved by Football Victoria, you will receive confirmation via email.

For more information on the affiliation process please contact:

Jimmy Soufis
Futsal & Schools Coordinator
Email: futsal@footballvictoria.com.au

Information provided by you in this form will be handled by FV in accordance with our Privacy Policy.

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Applicant's Details* This field is required.The authorised representative who is submitting the application on behalf of the Futsal Provider.

First Name

Last Name

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Applicant's Contact Details (Mobile)* This field is required.Mobile phone preferred

Phone

Mobile

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Applicant's Contact Details (Email)Email Address

example@example.com

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Futsal Provider Name* This field is required.Name of Provider (ie Legal Entity Name)

Preferred Provider/Centre Name

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ABN/ACN of Provider/Applicant* This field is required.

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Applicant’s Main Location* This field is required.Please provide details below regarding your organisation's main Futsal centre/program location

Suburb

Street

Municipality

Postcode

Futsal Centre

Number of Indoor Pitches at this location?

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Applicant’s Location 2 (if applicable)Please provide details below regarding your organisation's second location (if applicable)

Suburb

Street

Municipality

Postcode

Futsal Centre

Number of Indoor Pitches at this location?

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Applicant’s Location 3 (if applicable)Please provide details below regarding your organisation's second location (if applicable)

Suburb

Street

Municipality

Postcode

Futsal Centre

Number of Indoor Pitches at this location?

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Organisation Logo* This field is required.Please attach a copy of your logo as well as any variations

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Has your Centre/Program/Competition/Event previously been affiliated with Football Victoria?* This field is required.

YESNO

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What is the approximate quantity of Teams and Players you would have participating at your Centre/Program/Competition/Event?* This field is required.Approximate Only

Number of Teams

NUmber of Players

Approximate % of Female Participants to Male

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Please outline the reasons you wish to be affiliated with Football Victoria and the benefits it will provide within your local community* This field is required.

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Please indicate below any other affiliationsAffiliations include both formal and informal arrangements with other sports and 5-a-side, 7-a-side soccer.

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Please outline any past disciplinary records your centre has experienced (if any) whilst affiliated with any non-FV associations or non-affiliated Futsal or indoor football associationsPlease note that non-disclosure may result in your application being rejected

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Please outline a brief strategic direction and vision for your Centre/Program/Competition/Event or upload your organisation's Strategic Plan on the next page.

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Organisation's Strategic PlanPlease attach a copy of your logo as well as any variations

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Applicant’s Statement of Commitment to Child Safety* This field is required.A statement of commitment to child safety affirms the organisation's commitment to child safety by clearly stating that the organisation has: o Zero tolerance for child abuse o A commitment to children’s best interests and keeping them safe and o Actively works to listen to and empower children in the organisation Please use the below section to construct the Provider’s Statement of Commitment to Child Safety which incorporates the 3 points listed above.

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Will your Centre/Program/Competition/Event encourage participation for women and girls, and if so, what will your centre do to recruit teams and retain players?* This field is required.A strategic pillar for FV is to promote participation opportunities for female players

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How does your Centre/Program/Competition/Event propose it will cater to participants of all abilities and diverse backgrounds?* This field is required.Providing a safe and inclusive setting for all participants is a vital part of your affiliation, a great way to strengthen community involvement and also promotes you as a family friendly organisation.

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How does your Centre/Program/Competition/Event intend to support Futsal Refereeing and Futsal Coach Development moving forward?* This field is required.Do you have Futsal Referees and Futsal coaches that are in need of formal Futsal qualification/accreditation?

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Budget Information and Requirements* This field is required.

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Please upload your budget or financial statements from your organisation's Annual Report.* This field is required.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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TEAM ENTRIES

FV Futsal affiliates can enter a variety of teams across genders, age groups and levels, in the annual FV State Futsal Championships, affiliated social leagues and FV's premier Futsal League/Competition.

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Please outline if your organisation intends to setup representative teams made up from talented players and coaches for participation in the annual FV State Futsal Championships or F-League for juniors or seniors?* This field is required.

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Applicant’s Social Media Platforms* This field is required.Please paste the links below of your Social Media Accounts (Facebook, Instagram, Twitter, ect.)

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Applicant’s Website Address?* This field is required.

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Please provide any additional comments or information to support your application