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Details

2026 Australian Country Championships - WA Player Nominations

Fri 06 Mar 2026 09:00 - Sat 27 Jun 2026 18:00

Perth Hockey Stadium, Perth Hockey Stadium, Hayman Road, Bentley, 6102

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Basic details

First name*

Last name*

Phone number*

Email address*

Address*

Player First Name*

Player Surname*

Gender*

Date of Birth*

Residential Address*

Postcode*

Player Mobile Number*

Player Email Address*

Occupation + Workplace* Max 255 characters

Virgin Frequent Flyer Member Number

2025 Regional Club/Association Name*

Local Government/Shire*

Team & Division at the 2025 CBH State Country Championships at PHS*

Metro Club Name*

Primary Preferred Playing Position*

Secondary Preferred Playing Position*

Past Representative History* Max 255 characters

Emergency Contact Name*

Emergency Contact Email Address*

Emergency Contact Mobile Number*

Shirt Size*

Short/skirt size*

Please note

I am over 18, or, if I am under 18, this registration has been filled out by and endorsed by my parent or guardian.*