EOI for Country Nationals - Goulburn, NSW - 3rd-10th of August
Selectors and coaches are seeking to streamline selections during SA's State Country Championships being held at Mate Stadium on the 18th and 19th of May. Players making themselves eligable to participate in National Country Challenge, held on 3rd-10th of August in Goulburn, NSW are encourage to complete the survey.
Contact Details:
Name
*
First Name
Last Name
DOB
-
Month
-
Day
Year
Date
Gender:
Please Select
Female
Male
Non-binary
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Club/Association:
*
Are you dual registered?
Please Select
YES
NO
If answered yes, please answer what club:
Playing Details:
What is current your level of playing?
*
What is your prefered playing position?
*
Please Select
Striker
Midfielder
Defender
Goalkeeper
Please indicate the country association you will be representing at SA Country Champs
*
Please provide the number that will be on your guernsey at State Country Championship
*
Are you available for selection in the 2024 Hockey Australia Country Challenge will be held on 3-10 August in Goulburn, NSW
*
Please Select
YES
NO
Did you represent SA last year in the 2023 Country Challenge?
*
Please Select
YES
NO
Pre-existing Injuries
Are you currently injured or have any pre-existing injuries?
*
Please Select
YES
NO
If answered YES, where is the injury/injuries located?
Medical/support Services
Medicare Number (Include your ID number)
*
Private Medical Insurance Fund (if none type nil) eg. GMHBA
*
Private Medical insurance membership number (if none type "nil") Include your ID Number e.g. 2-1345566*Your answer
*
Ambulance Membership Number (if none type nil)
*
Please tick if you have any of the following conditions
Epilepsy
Migraines/Severe Headaches
Concussion symptoms
Diabetes
Asthma
Anxiety/Depression
Cardiovascular Disease
Do you have allergies?
*
If answered yes, please list your allergies
Submit
Should be Empty: