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https://ifj.formstack.com/forms/request_for_withdrawal
Submission: On October 18 via manual from US — Scanned from DE
Submission: On October 18 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
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<div id="translatedWord-fields" style="display:none;">Fields</div>
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<h1 style="text-align: center;"><img src="https://s3.amazonaws.com/files.formstack.com/public/373726/image_New_IndianaFireAcademy_logo_FINAL_FINAL4132201.png" style="width: 300px;" class="fr-fic fr-dib"></h1>
<h2 style="text-align: center;">Indiana Fire Academy Team Release or Suspended Billing due to Injury Request</h2>
<p><span style="font-size: 14px;"><br></span></p>
<p><span style="font-size: 14px;">All players who register with the Indiana Fire Academy travel soccer program are expected to fulfill their one-year obligation to their team and club. However, circumstances can arise. To be considered for
release from participating with you Indiana Fire Academy team, please fill out the information below. Your information will be forwarded to the appropriate Director of Coaching, who will notify you of his or her decision. If your player
is injured and will be unable to participate for more than 60 days you can use this form to request a suspension of their monthly payments.</span></p>
</div>
<div class="fs-clear"></div>
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<div id="fsRow2181219-2" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100 fsHiddenByFieldSetting" id="fsCell37506562" lang="en" fs-field-type="textarea" fs-field-validation-name="Approval Comments">
<textarea id="field37506562" class="fsField " name="field37506562" rows="7" cols="80">Garry/Brandon/Diego/Shane/Gary: click approve or deny and then list A, B, C or D in the Comment box.
A. Stays on roster is not released but will not participate.
B. Stays on roster may return later to participate.
C. Remove from roster. Player eligible to roster with another club.
D. List reason for denial.</textarea>
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<div class="fs-clear"></div>
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<span id="label37402130" class="fsLabel fsRequiredLabel">Player name<span class="fsRequiredMarker">*</span></span>
<div class="fsSubFieldGroup">
<div class="fsSubField fsNameFirst">
<input type="text" id="field37402130-first" name="field37402130-first" size="20" aria-label="First Name" value="" required="" class="fsField fsFieldName fsRequired" aria-required="true">
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</div>
<div class="fsSubField fsNameLast">
<input type="text" id="field37402130-last" name="field37402130-last" size="20" aria-label="Last Name" value="" required="" class="fsField fsFieldName fsRequired" aria-required="true">
<label class="fsSupporting fsRequiredLabel" for="field37402130-last">Last Name<span class="hidden">*</span></label>
</div>
</div>
<div class="clear"></div>
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<div class="fs-clear"></div>
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<div id="fsRow2181219-4" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell37404689" lang="en" fs-field-type="select" fs-field-validation-name="Choose player program">
<label id="label37404689" class="fsLabel fsRequiredLabel" for="field37404689">Choose player program<span class="fsRequiredMarker">*</span> </label>
<select id="field37404689" name="field37404689" size="1" required="" class="fsField fsRequired" aria-required="true">
<option value=""> </option>
<option value="Girls Youth Travel Program U8-U12">Girls Youth Travel Program U8-U12</option>
<option value="Girls Travel U13-U19">Girls Travel U13-U19</option>
<option value="Boys Youth Travel Program U8-U12">Boys Youth Travel Program U8-U12</option>
<option value="Boys Travel U13-U19">Boys Travel U13-U19</option>
<option value="ECNL">ECNL</option>
<option value="ECNL RL">ECNL RL</option>
<option value="MLS Next">MLS Next</option>
</select>
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<div class="fs-clear"></div>
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<div class="fsRowBody fsCell fsFieldCell fsFirst fsLabelVertical fsSpan33" id="fsCell37404785" lang="en" fs-field-type="select" fs-field-validation-name="Player age group for 2023-2024">
<label id="label37404785" class="fsLabel fsRequiredLabel" for="field37404785">Player age group for 2023-2024<span class="fsRequiredMarker">*</span> </label>
<select id="field37404785" name="field37404785" size="1" required="" class="fsField fsRequired" aria-required="true">
<option value=""> </option>
<option value="U8 2016/2017">U8 2016/2017</option>
<option value="U9 2015">U9 2015</option>
<option value="U10 2014">U10 2014</option>
<option value="U11 2013">U11 2013</option>
<option value="U12 2012">U12 2012</option>
<option value="U13 2011">U13 2011</option>
<option value="U14 2010">U14 2010</option>
<option value="U15 2009">U15 2009</option>
<option value="U16 2008">U16 2008</option>
<option value="U17 2007">U17 2007</option>
<option value="U18 2006">U18 2006</option>
<option value="U19 2005">U19 2005</option>
</select>
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<label id="label37404825" class="fsLabel fsRequiredLabel" for="field37404825">Player gender<span class="fsRequiredMarker">*</span> </label>
<select id="field37404825" name="field37404825" size="1" required="" class="fsField fsRequired" aria-required="true">
<option value=""> </option>
<option value="Boy">Boy</option>
<option value="Girl">Girl</option>
</select>
</div>
<div class="fsRowBody fsCell fsFieldCell fsLast fsLabelVertical fsHidden fsSpan33" id="fsCell37404870" lang="en" fs-field-type="select" fs-field-validation-name="Travel">
<label id="label37404870" class="fsLabel" for="field37404870">Travel </label>
<select id="field37404870" name="field37404870" size="1" class="fsField" disabled="disabled">
<option value=""> </option>
<option value="NL">NL</option>
<option value="Red">Red</option>
<option value="Red II">Red II</option>
<option value="White">White</option>
<option value="White II">White II</option>
<option value="Navy">Navy</option>
<option value="IDP">IDP</option>
</select>
</div>
<div class="fs-clear"></div>
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<div id="fsRow2181219-6" class="fsRow fsFieldRow fsLastRow">
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<h2>Club policy</h2>
<p><span style="font-size: 14px;">Club policy states that "if the Player quits or terminates his or her relationship with the Club, then the entire balance remaining unpaid under this Agreement shall thereupon become immediately due and
payable and such obligation shall survive the expiration or earlier termination of this Agreement.<br></span></p>
<p><span style="font-size: 14px;">"Notwithstanding the foregoing, the Player may terminate this Agreement if the Player is injured and provides a report from a licensed physician that the Player is not physically able to play soccer during
the remainder of the Term. The Player may also terminate this Agreement if the Player moves more than sixty (60) miles from downtown Westfield, Indiana. In the event that this Agreement is terminated due to an injury or a move, as
described above, the annual fee (to the extent previously paid for any period following such date) will be refunded a pro rata basis, to be determined at time of the move or injury documentation."</span></p>
<p><span style="font-size: 14px;">If a player is injured and unable to participate for more than 60 days we will suspend their monthly payments and will resume payments if and when they are able to return at a pro rated amount.</span></p>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-7" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell37402280" lang="en" fs-field-type="radio" fs-field-validation-name="Reason for requesting separation or billing suspension">
<fieldset role="group" aria-labelledby="fsLegend37402280" id="label37402280">
<legend id="fsLegend37402280" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Reason for requesting separation or billing suspension<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field37402280_1"><input type="radio" id="field37402280_1" name="field37402280" value="Moving more than 60 miles from Westfield (list destination below)" class="fsField fsRequired vertical"
aria-required="true">Moving more than 60 miles from Westfield (list destination below)</label>
<label class="fsOptionLabel vertical" for="field37402280_2"><input type="radio" id="field37402280_2" name="field37402280" value="Injury that precludes playing with the team (please attach documentation below)"
class="fsField fsRequired vertical" aria-required="true">Injury that precludes playing with the team (please attach documentation below)</label>
<label class="fsOptionLabel vertical" for="field37402280_3"><input type="radio" id="field37402280_3" name="field37402280" value="Other extenuating circumstances (please list below)" class="fsField fsRequired vertical"
aria-required="true">Other extenuating circumstances (please list below)</label>
<label class="fsOptionLabel vertical" for="field37402280_4"><input type="radio" id="field37402280_4" name="field37402280" value="Player injured and unable to participate (list details below)" class="fsField fsRequired vertical"
aria-required="true">Player injured and unable to participate (list details below)</label>
</div>
</fieldset>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-8" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell37402631" lang="en" fs-field-type="text" fs-field-validation-name="List city where Player will be moving">
<label id="label37402631" class="fsLabel fsRequiredLabel" for="field37402631">List city where Player will be moving<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field37402631" name="field37402631" size="100" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true" disabled="disabled">
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-9" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell37402463" aria-describedby="fsSupporting37402463" lang="en" fs-field-type="textarea" fs-field-validation-name="Extenuating circumstances">
<label id="label37402463" class="fsLabel fsRequiredLabel" for="field37402463">Extenuating circumstances<span class="fsRequiredMarker">*</span> </label>
<textarea id="field37402463" class="fsField fsRequired " name="field37402463" rows="10" cols="100" required="" aria-required="true" disabled="disabled"></textarea>
<div id="fsSupporting37402463" class="fsSupporting">Please list reason for requesting a release from the club.</div>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-10" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell68670764" aria-describedby="fsSupporting68670764" lang="en" fs-field-type="textarea"
fs-field-validation-name="Billing suspension details. ">
<label id="label68670764" class="fsLabel fsRequiredLabel" for="field68670764">Billing suspension details. <span class="fsRequiredMarker">*</span> </label>
<textarea id="field68670764" class="fsField fsRequired " name="field68670764" rows="10" cols="100" required="" aria-required="true" disabled="disabled"></textarea>
<div id="fsSupporting68670764" class="fsSupporting">Please describe the injury, expected treatment and estimated month they can return. </div>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-11" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell37402526" aria-describedby="fsSupporting37402526" lang="en" fs-field-type="file" fs-field-validation-name="Physician report">
<fieldset role="group" aria-labelledby="fsLegend37402526" id="label37402526">
<legend id="fsLegend37402526" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Physician report<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<input type="file" style="display: none" id="field37402526" name="field37402526" size="30" required="" aria-required="true"
class="fsField fsUpload uploadTypes-jpg,jpeg,gif,png,bmp,tif,psd,pdf,doc,docx,xls,xlsx,txt,mp3,mp4,aac,wav,au,wmv,avi,mpg,mpeg,zip,gz,rar,z,tgz,tar,sitx fsRequired" disabled="disabled">
<input type="button" class="fsFileUploadButton" id="field37402526UploadButton" aria-controls="field37402526" value="Choose File" disabled="">
<input type="button" class="fsFileUploadButton" id="field37402526DeleteButton" aria-controls="field37402526" value="Remove File" disabled="">
<span class="fsFileUploadName" id="field37402526FileName">No File Chosen</span>
<div class="showMobile">File uploads may not work on some mobile devices.</div>
<script>
(function() {
var filename = document.getElementById('field37402526FileName').innerHTML
function fileUploadClick() {
var field = document.getElementById('field37402526');
field.click();
}
function fileDelete() {
document.getElementById('field37402526').value = '';
document.getElementById('field37402526FileName').innerHTML = filename;
}
function onFileChange(event) {
if (!event.target.files || !event.target.files.length) {
return;
}
var file = event.target.files[0];
var name = document.getElementById('field37402526FileName');
name.innerHTML = file.name;
}
var button = document.getElementById('field37402526UploadButton');
button.addEventListener('click', fileUploadClick);
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field.addEventListener('change', onFileChange);
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buttonDelete.addEventListener('click', fileDelete);
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<div id="fsSupporting37402526" class="fsSupporting">Please upload a copy of a medical report or letter from a physician that details why the player can no longer participate in soccer.</div>
</div>
</fieldset>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-12" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell37402774" lang="en" fs-field-type="radio"
fs-field-validation-name="Remaining balance - After review by the respective Director of Coaching and the Business Director, families requesting a release will be presented with a balance due as referenced by the club policy above. Please list how you wish to pay the remaining balance. Committed players are also responsible for paying their team fees for the season if they leave the team or are injured and unable to participate for a portion of the season.">
<fieldset role="group" aria-labelledby="fsLegend37402774" id="label37402774">
<legend id="fsLegend37402774" class="fsLabel fsRequiredLabel fsLabelVertical"><span>Remaining balance - After review by the respective Director of Coaching and the Business Director, families requesting a release will be presented with a
balance due as referenced by the club policy above. Please list how you wish to pay the remaining balance. Committed players are also responsible for paying their team fees for the season if they leave the team or are injured and
unable to participate for a portion of the season.<span class="fsRequiredMarker">*</span></span></legend>
<div class="fieldset-content">
<label class="fsOptionLabel vertical" for="field37402774_1"><input type="radio" id="field37402774_1" name="field37402774" value="Charge the entire remaining balance immediately to the card on my Player's GotSport account."
class="fsField fsRequired vertical" aria-required="true">Charge the entire remaining balance immediately to the card on my Player's GotSport account.</label>
<label class="fsOptionLabel vertical" for="field37402774_2"><input type="radio" id="field37402774_2" name="field37402774"
value="Continue the monthly automatic billing, less any cost reductions due to injury or other qualifying circumstances." class="fsField fsRequired vertical" aria-required="true">Continue the monthly automatic billing, less any cost
reductions due to injury or other qualifying circumstances.</label>
<label class="fsOptionLabel vertical" for="field37402774_3"><input type="radio" id="field37402774_3" name="field37402774"
value="Pay by check within 10 days of my balance notification. (Failure to pay will result in an automatic billing of the entire amount via GotSport.)" class="fsField fsRequired vertical" aria-required="true">Pay by check within 10
days of my balance notification. (Failure to pay will result in an automatic billing of the entire amount via GotSport.)</label>
<label class="fsOptionLabel vertical" for="field37402774_4"><input type="radio" id="field37402774_4" name="field37402774" value="Will resume pro rated monthly payments if and when player is able to return"
class="fsField fsRequired vertical" aria-required="true">Will resume pro rated monthly payments if and when player is able to return</label>
<label class="fsOptionLabel vertical" for="field37402774_5"><input type="radio" id="field37402774_5" name="field37402774" value="Other (list reasons below)" class="fsField fsRequired vertical" aria-required="true">Other (list reasons
below)</label>
</div>
</fieldset>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-13" class="fsRow fsFieldRow fsLastRow fsHidden">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsHidden fsSpan100" id="fsCell37402977" aria-describedby="fsSupporting37402977" lang="en" fs-field-type="textarea"
fs-field-validation-name="Other suggested payment option request">
<label id="label37402977" class="fsLabel fsRequiredLabel" for="field37402977">Other suggested payment option request<span class="fsRequiredMarker">*</span> </label>
<textarea id="field37402977" class="fsField fsRequired " name="field37402977" rows="10" cols="100" required="" aria-required="true" disabled="disabled"></textarea>
<div id="fsSupporting37402977" class="fsSupporting">(Must be approved by Director of Coaching and Business Director.)</div>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-14" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell37403077" lang="en" fs-field-type="richtext" fs-field-validation-name="">
<p><strong>Please note </strong>- With the exception of a geographical move more than 60 miles from Westfield, all Players will remain registered with the Indiana Fire Academy through May 2024. This precludes the ability to register
with another travel soccer club anytime in the 2023-24 season.</p>
</div>
<div class="fs-clear"></div>
</div>
<div id="fsRow2181219-15" class="fsRow fsFieldRow fsLastRow">
<div class="fsRowBody fsCell fsFieldCell fsFirst fsLast fsLabelVertical fsSpan100" id="fsCell37403866" lang="en" fs-field-type="text" fs-field-validation-name="Name of person filling out this form">
<label id="label37403866" class="fsLabel fsRequiredLabel" for="field37403866">Name of person filling out this form<span class="fsRequiredMarker">*</span> </label>
<input type="text" id="field37403866" name="field37403866" size="50" required="" value="" class="fsField fsFormatText fsRequired " aria-required="true">
</div>
<div class="fs-clear"></div>
</div>
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<div class="fsRowBody fsCell fsFieldCell fsFirst fsLabelVertical fsSpan33" id="fsCell37403880" lang="en" fs-field-type="phone" fs-field-validation-name="Phone">
<label id="label37403880" class="fsLabel fsRequiredLabel" for="field37403880">Phone<span class="fsRequiredMarker">*</span> </label>
<input type="tel" id="field37403880" name="field37403880" size="20" required="" value="" class="fsField fsFormatPhoneUS fsRequired" aria-required="true" data-country="US" data-format="national">
</div>
<div class="fsRowBody fsCell fsFieldCell fsLabelVertical fsSpan33" id="fsCell37403884" lang="en" fs-field-type="email" fs-field-validation-name="Email">
<label id="label37403884" class="fsLabel fsRequiredLabel" for="field37403884">Email<span class="fsRequiredMarker">*</span> </label>
<input type="email" id="field37403884" name="field37403884" size="50" required="required" value="" class="fsField fsFormatEmail fsRequired" aria-required="true">
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<div class="fs-clear"></div>
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<input id="fsSubmitButton2181219" class="fsSubmitButton" style="" type="submit" value="Submit Form">
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ERROR:JAVASCRIPT IS NOT ENABLED. YOU MUST ENABLE JAVASCRIPT IN YOUR BROWSER TO USE THIS FORM Please fill in a valid value for all required fields Please ensure all values are in a proper format. Are you sure you want to leave this form and resume later? Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form. Save and Resume Later Save and get link You must upload one of the following file types for the selected field: There was an error displaying the form. Please copy and paste the embed code again. Apply Discount You saved with code Submit Form Submitting Validating There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue. Please check the field: Fields INDIANA FIRE ACADEMY TEAM RELEASE OR SUSPENDED BILLING DUE TO INJURY REQUEST All players who register with the Indiana Fire Academy travel soccer program are expected to fulfill their one-year obligation to their team and club. However, circumstances can arise. To be considered for release from participating with you Indiana Fire Academy team, please fill out the information below. Your information will be forwarded to the appropriate Director of Coaching, who will notify you of his or her decision. If your player is injured and will be unable to participate for more than 60 days you can use this form to request a suspension of their monthly payments. Garry/Brandon/Diego/Shane/Gary: click approve or deny and then list A, B, C or D in the Comment box. A. Stays on roster is not released but will not participate. B. Stays on roster may return later to participate. C. Remove from roster. Player eligible to roster with another club. D. List reason for denial. Player name* First Name* Last Name* Choose player program* Girls Youth Travel Program U8-U12 Girls Travel U13-U19 Boys Youth Travel Program U8-U12 Boys Travel U13-U19 ECNL ECNL RL MLS Next Player age group for 2023-2024* U8 2016/2017 U9 2015 U10 2014 U11 2013 U12 2012 U13 2011 U14 2010 U15 2009 U16 2008 U17 2007 U18 2006 U19 2005 Player gender* Boy Girl Travel NL Red Red II White White II Navy IDP CLUB POLICY Club policy states that "if the Player quits or terminates his or her relationship with the Club, then the entire balance remaining unpaid under this Agreement shall thereupon become immediately due and payable and such obligation shall survive the expiration or earlier termination of this Agreement. "Notwithstanding the foregoing, the Player may terminate this Agreement if the Player is injured and provides a report from a licensed physician that the Player is not physically able to play soccer during the remainder of the Term. The Player may also terminate this Agreement if the Player moves more than sixty (60) miles from downtown Westfield, Indiana. In the event that this Agreement is terminated due to an injury or a move, as described above, the annual fee (to the extent previously paid for any period following such date) will be refunded a pro rata basis, to be determined at time of the move or injury documentation." If a player is injured and unable to participate for more than 60 days we will suspend their monthly payments and will resume payments if and when they are able to return at a pro rated amount. Reason for requesting separation or billing suspension* Moving more than 60 miles from Westfield (list destination below) Injury that precludes playing with the team (please attach documentation below) Other extenuating circumstances (please list below) Player injured and unable to participate (list details below) List city where Player will be moving* Extenuating circumstances* Please list reason for requesting a release from the club. Billing suspension details. * Please describe the injury, expected treatment and estimated month they can return. Physician report* No File Chosen File uploads may not work on some mobile devices. Please upload a copy of a medical report or letter from a physician that details why the player can no longer participate in soccer. Remaining balance - After review by the respective Director of Coaching and the Business Director, families requesting a release will be presented with a balance due as referenced by the club policy above. Please list how you wish to pay the remaining balance. Committed players are also responsible for paying their team fees for the season if they leave the team or are injured and unable to participate for a portion of the season.* Charge the entire remaining balance immediately to the card on my Player's GotSport account. Continue the monthly automatic billing, less any cost reductions due to injury or other qualifying circumstances. Pay by check within 10 days of my balance notification. (Failure to pay will result in an automatic billing of the entire amount via GotSport.) Will resume pro rated monthly payments if and when player is able to return Other (list reasons below) Other suggested payment option request* (Must be approved by Director of Coaching and Business Director.) Please note - With the exception of a geographical move more than 60 miles from Westfield, all Players will remain registered with the Indiana Fire Academy through May 2024. This precludes the ability to register with another travel soccer club anytime in the 2023-24 season. Name of person filling out this form* Phone* Email* Previous← Next→ Powered by Formstack Create your own form › Enter your save and resume password Cancel Confirm