Details

2026 SCIH Rep Team Official Nomination + Medical Form

Fri 02 Oct 2026 09:00 - Sun 29 Nov 2026 16:00

TBA

Google · Outlook · iCal

Are you attending this event?

Yes No Maybe

First name*

Last name*

Phone number*

Email address*

Address*

What Position are you nominating for?

What Championship is this relating to?*

Please provide your Blue Card (WWC) Number and Expiry date*

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?*

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

By nominating, you are agreeing to become a member of SCIH, hold a current blue card and have full availability for the State Championships.

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.*

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.