2027 Junior Representative Team Trials
Saturday 7th November 2026
Please Note: This form is only for players who have not participated in the 2026 Prep4Rep Program
Athletes Name
*
First Name
Last Name
Date of Birth
*
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Format: 0000 000 000.
Email Address
*
example@example.com
Teams trialling for (please tick those that apply):
*
Inter District (ID)
Junior State Age (JSA)
1st Preferred Position:
*
Please Select
Goal Shooter
Goal Attack
Wing Attack
Centre
Wing Defence
Goal Defence
Goal Keeper
2nd Preferred Position:
*
Please Select
Goal Shooter
Goal Attack
Wing Attack
Centre
Wing Defence
Goal Defence
Goal Keeper
Previous Playing Experience:
*
Emergency Contact
Name
*
First Name
Last Name
Relationship
*
Home Number
Please enter a valid phone number.
Format: 0000 000 000.
Mobile Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Health Care Details
Medicare Number
*
Position on Card
*
Expires
*
Private Health Insurance:
*
Yes
No
Fund & Number
Private Doctor:
*
Phone Number
*
Please enter a valid phone number.
Format: 0000 000 000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical History
Examples of these include but are in no way limited to: *Asthma *Diabetes *Epilepsy *Spinal Injuries *Arthritis. Please also notify us if this affects your performance.
Do you have any medical conditions that you, in consultation with your doctor, consider appropriate to notify us of prior to representative duties?
*
Yes
No
Other
If so, please provide details here:
Do you have any allergies?
*
Yes
No
If Yes Reactions/Treatment
Sports Injuries
Please describe any sports injuries have been sustained in the last 2 years: For each injury, please state type of Injury (e.g. dislocation, strain, tear, fracture) approx. date of injury and treatment received (e.g. physio, surgery)
Do you have any sports injuries?
*
Yes
No
Not Sure
Please list them.
Do you give permission for the coach or manager to administer Panadol to your child?
*
Please Select
Yes
No
My Products
*
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Trial Only Fee
$25.00 AUD
$
25.00
AUD
Quantity
1
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Credit Card
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