Register First Name Last Name Street Address City State NSW VIC Post Code Email Phone Gender Male Female Date of Birth Hockey ACT Number (if known) ~ Type '00' if unknown Highest level of outdoor Hockey you have played Season 2025-2026 Division Selection Mixed Senior Premier LeagueSenior WomenU14 Mixed + Payment Terms Paid in full by Round 4 I agree to adhere to the payment terms selected above. Fees are as follows Rules Agree Disagree In the event of my/my child's admission as a member, I/my child agree to be bound by the rules of Border Indoor Hockey for the period of membership. Uniforms Agree Disagree I acknowledge that my uniform stays the property of Border Indoor Hockey. A levy is included as part of my registration fees. I am required to return my uniform at the end of the season competition. Who is your winter club? Have you played with Border Indoor Hockey before? Yes No Photographs Agree Disagree I give permission for Photographs of myself/my child to appear on the Border Indoor Hockey website or in other forms of media releases & to include my name. Code of Conduct Agree Disagree I/and or my child have read & understood & agree to abide by the "Code of Conduct" of Border Indoor Hockey. All members & supporters of Border Indoor Hockey shall conduct themselves in the spirit of good sportsmanship & show respect to teammates, officials & spectators at all time. Health Statement Do you suffer from Asthma? Yes No Do you suffer from Diabetes? Yes No Do you suffer from Epilepsy? Yes No Do you suffer from any allergies? Yes No Do you require any medication whilst playing Hockey? Yes No Do you have any other medical conditions that we should be aware of? Yes No Do you have ambulance cover? Yes No Emergency Contact Person Emergency Contact Address Emergency Contact Person Phone Consent for Medical Treatment Agree Disagree If deemed necessary, I authorise the Coach/Manager/Club person to consent to me/my child receiving emergency medical treatment and/or use of an ambulance as may be necessary. Consent for Medical Disclosure Agree Disagree I consent to my team manager/coach having the above health information. Volunteer Umpire Coach Set up Tech Bench EXPRESSION OF INTEREST: PLAYERS, PARENTS, SPECTATORS & other SUPPORTERS please tick many areas you may be interested in assisting, supporting or becoming involved in, with Border Indoor Hockey. All players are to pack down at the end of the last game. How did you hear about us? Social Media School Google Friend Family Other Date Name/Signature Name & Validation of the applicant or guardian/parent (if the applicant is 18 years or under) Name: Signature* Your application is subject to approval by Border Indoor Hockey committee. Submit