Intercity Challenge 2023 – ACT Masters Hockey

Name(Required)

First Last

Gender(Required)

Male

Female

Email(Required)

Enter Email Confirm Email

Mobile Phone(Required)

Emergency Contact Name(Required)

Can NOT be you.

Emergency Mobile Phone Contact(Required)

Birth Date(Required)

With the date picker below, in some web browsers you will get a calendar to choose from, others will only allow you to click on day/month/year and change them as required.

Age division you are nominating for:(Required)

Masters; 34 to 45s

Senior Masters; 46 to 55s

Grand Masters; 56 to 65s

Legends; 66 and over

Player and or official?(Required)

Player

Manager

Coach

Support Staff

Umpire

Technical Official

Please enter your valid 2023 RevSPORT number(Required)

(Renewal in 2023 is a condition of selection)

Do you have a current ACT representative playing shirt?(Required)

Yes

Shirt number(Required)

Please enter a number from 1 to 99.

Additional shirt number

Preferred playing position 1(Required)

Preferred playing position 2(Required)

Address (no PO Boxes)(Required)

Street Address City State Postcode

2023 Nomination Form - Intercity Challenge