Details

2026 SCIH Open Men Rep Player Nomination + Medical Form

Fri 27 Nov 2026 09:00 - Sun 29 Nov 2026 16:00

Brisbane Indoor Hockey, Kedron State High School, Park Road, Ked

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Basic details

First name*

Last name*

Phone number*

Email address*

Address*

Additional information

Playing Position*

Attacker

Defender

Goal Keeper

Other relevant Information Max 255 characters

Emergency Contact Name*

Emergency Contact Number*

Relationship to Nominee*

Medicare Card Number*

Do you have Private Health Insurance?*

Do you suffer from any of the following?

Asthma

Diabetes

Epilepsy

Heart Condition

Other illnesses/disease

If you have selected any of the above, please provide details Max 255 characters

Are you taking any medications?*

Any current injuries or conditions?*

If player is under 18 years of age, name of parent or guardian completing form

Please note

All prices are inclusive of GST.
A Registration fee of $25.00 applies for this event.

Event Waiver

Any players who have not paid a full HA/HQ Membership and a player registration with Sunshine Coast Hockey, will not be permitted to play at the State Championships, unless called upon via a the HQ clearance process.

By nominating, you are agreeing to a commitment for trials, the trial process and full availability for the State Championships. You are of the understanding that the registration fee is refundable in the event you are not selected to represent SCIH, a withdrawal due to injury (medical certificate required) or extenuating circumstances.

For players to be covered by insurance during the trial period, you must have an upto date HA/HQ membership for 2026.

I confirm that I have read the above Event Waiver in its entirety.*

I agree to the Event Waiver.*

I am over 18, or, if I am under 18, this registration has been filled out by and endorsed by my parent or guardian.*

Event registration

Already a member?

Details

Basic details

Additional information

Event Waiver