Player Selection Nomination Form

PLAYER SELECTION NOMINATION FORM

PERSONAL DETAILS (All details to be typed and emailed as a Word document – Not PDF or scanned)
NAME / DATE of Birth
ADDRESS
CONTACT PHONE NUMBER / EMAIL ADDRESS: please be sure this is entered clearly:
Association currently registered with / Association playing for at State Championships

CONTACT THE SECRETARY IF YOU HAVE NOT RECEIVED AN ACCEPTANCE EMAILWITHIN A WEEK OF LODGING THIS FORM

Please complete the details below in full:

Year of nomination / Age Group coinciding with your birthdate / OVER
Playing position: See definition below:-
Defender(Fullback/Wing half), Midfield(Centre Half/Inners), Striker (Wings/Centre Forward) / 1st Playing position preference
2ndPlaying position preference
Most recent representation for NSW (Year & age group)
Last year did you represent any other State; (which state and age) / Yes/No
Have you represented AUSTRALIA previously (most recent representation – Year & age group) / Yes/No
If successful in being selected for NSW would you like to taken into consideration to be part of the teams leadership group / Yes/No
Have you any medical condition that may affect your performance / Yes/No:
Do you have any injury that may affect your performance / Yes/No:
If you are unsuccessful in being selected for NSW would you like your contact details to be supplied to other States / Yes/No
Have you made leave arrangement for Lismore/Ballina / Yes/No
Will you have your own transport in Lismore/Ballina / Yes/No
Will you be arranging your own accommodation in Lismore/Ballina / Yes/No
NOTES (In relation to questions above)
DECLARATION
Insubmitting this nomination I hereby nominate for selection for a NSW Men’s Masters teamto compete in this year’s Australian Men’s Masters Hockey Championships. I agree to abide by Hockey NSW Men’s Masters Subcommittee policies and procedures and understand I must be available for the duration of the National Championships and NSW State training is compulsory. I further understand and will abide with the payment of the players fee together with travel and accommodation payments.

Please return form electronically to: