2026 Junior Country Regionals Pick Up Pool Form

2026 Junior Country Championships Pick Up Pool Form

Please fill out this form below to register and apply for the 2026 Junior Country Championships pickup pool
Personal Details:
Player Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Competition:
Country Association:
**Please enter the region to which you trialled for and were unsuccessful or who did not enter a team**
Position
Emergency Contact Details:
Parent Name

First NameLast Name
Email:
example@example.com
Relationship to the player:
Emergency Phone Number
Format: (000) 000-0000.
Pre-existing Injuries
Are you currently injured or have any pre-existing injuries?
If answered YES, where is the injury/injuries located?
Medical:
Please tick if you have any of the following conditions
If yes to the above question, please explain further
Do you have any allergies?
If Yes please list your allergies
Prescription Medication
Are you currently taking any prescription or non-prescription medication? e.g. Asthma Puffer
If yes, please list details (i.e. name of medication/dosage etc)
HSA Player Code of Conduct
I have and read and agree to Hockey SA Player Code of Conduct
Should be Empty:

2026 Junior Country Championships Pick Up Pool Form