Expression of Interest Form - Mens Australian Shield

Full Name

First NameLast Name

Rugby ID Number

Can be found in Rugby Xplorer Profile

Date Of Birth

Date

Primary Email Address

example@example.com

Primary Phone Number

Please enter a valid phone number.Format: 0000 000 000.

I confirm that I am interest in participating in the trial process for the QSRU Mens Representative team for 2026.

To be considered for selection, I understand that I must be able to attend the Australian Rugby Shield held in Newcastle from 7 - 11 October at a cost of approximately $500 (estimated cost including travel, accommodation and kit. Food and drinks are not included).

What grade do you play?

Current club?

What position/s do you play?

Any previous concussions?

Please provide date/s of your concussions.

Any current injuries / recent surgery / chronic illnesses / medication regimes, that will impact your ability to fully participate in trainings and game components of this process?

Please provide details of your injury / recovery / ability to participate.

Any food allergies or special meal requirements?

Please provide details of food allergies and/or special meal requirements.

Jersey size

Shorts size

Socks size

I can confirm that the information provided is accurate to the best of my knowledge and if at any stage, I am unable to continue with the selection process due to injury and/or changed circumstances with regards to attendance at mandatory sessions, travel and/or commitment to pay the Player Levy deposit and final payments by the due dates, I will notify QSRU immediately.