Basic details

First name*

Last name*

Phone number*

Email address*

Address*

Additional information

Player Name*

Player DOB*

Player Email*

Player Contact Number*

Guardian Name

Registered Club*

Banks Hockey Club

Commerce Pints Hockey club

East Darwin

Hockey Club

Palmerston Saints

Hockey Club

Nightcliff Tigers Hockey Club

Waratah Hockey Club

other

If other club, please advise

Preferred Playing Position - 1*

Preferred Playing Position - 2*

Do you have a previous or current injury or illness*

If yes, please provide details*

I have read and understand the Social Media Policy*

Yes

I have read and understand the Players Code of Conduct*

Yes

Emergency Contact Name*

Emergency contact Number*

Guardian Contact No

Please note

To be eligible for selection, the Player Nomination must be completed, along with payment of the $50.00 Nomination fee.

If you are currently unfinancial with Hockey NT, your nomination may not be accepted.

Hockey NT will also confirm your financial status with your Club. If you are deemed to be unfinancial you will be contacted accordingly.

I confirm that I have read the above Terms Of Registration in its entirety.*

I agree to the Terms Of Registration.*