Basic details

First name*

Last name*

Phone number*

Email address*

Address*

Additional information

Name*

Date of Birth*

Address* Max. 255 characters

I am registering for*

O40's

O45's

O50's

O55's

O60's

O65's

Registered Club

Banks Hockey Club

Commerce Pints Hockey Club

East Darwin Hockey club

Nightcliff Tigers Hockey Club

Palmerston Saints Hockey club

Waratah Hockey Club

If other club please advise club name

Preferred Playing Position #1*

Preferred Playing Position #2*

Do you have any pre-existing/current injury?*

If yes, Please provide details* Max. 255 characters

Emergency Contact Name*

Emergency contact Phone Number*

I have read and understood the Social Media Policy*

Yes

No

I agree to the use of my image being used (i.e photos)*

Yes

No

Please note

All prices are inclusive of GST.
A Booking fee of $50.00 applies for this event.

Terms Of Registration

If selected $50.00 will be deducted from your levy. If not selected $50.00 will not be refunded.

If you are selected then withdraw the nomination fee will be forfeited.

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.*

Already a member?

Details

Basic details

Additional information

Terms Of Registration