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Loreto 3rd Level Student Training, pay as you go
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Indoor St. Peter’s College
Wexford Hockey Club Health Questionnaire Form
Wexford Hockey Club Adult Member Registration Form
Wexford Hockey Club Junior Member Registration Form
CONTACT
ONLINE STORE
FORMS
Social Hockey
Memberships
Loreto 3rd Level Student Training, pay as you go
Loreto 3 Day Primary School Training
Indoor St. Peter’s College
Wexford Hockey Club Health Questionnaire Form
Wexford Hockey Club Adult Member Registration Form
Wexford Hockey Club Junior Member Registration Form
CONTACT
ONLINE STORE
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ABOUT
FIXTURES & RESULTS
GALLERY
FORMS
Membership Payment
Social Hockey
Indoor, St. Peter’s
Loreto 3 Day Primary School Training
Loreto 3rd Level Student Training, pay as you go
Wexford Hockey Club Junior Member Registration
Wexford Hockey Club Health Questionnaire Form
Wexford Hockey Club Adult Member Registration Form
CONTACT
ONLINE STORE
Membership Payment
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Submission ID
Who is Completing the Registration Process?
(Required)
Please Select..
A Parent Registering A Child / Children
Adult Registering Themselves / Multiple Players
How Many Players Are Being Registrered?
(Required)
Please Select..
1
2
3
4
What Fee's Do You Wish to Pay?
(Required)
Please Select..
Full Fee's
Half Fee's
Full Fee's / Half Fee's
Full Fee Membership Selections
Please select the quantity of memberships required per age group.
Maximum of 4 Memberships Total.
Primary School Membership
None
1 Child
2 Children
3 Children
4 Children
Secondary School Membership
None
1 Child
2 Children
3 Children
4 Children
Third Level Education Membership
None
1 Member
2 Members
3 Members
4 Members
Adult Unwaged Membership
None
1 Member
2 Members
3 Members
4 Members
Adult Membership
None
1 Member
2 Members
3 Members
4 Members
Half Fee Membership Selections
Please select the quantity of memberships required per age group. Maximum of 4 Memberships Total.
Primary School Membership
None
1 Child
2 Children
3 Children
4 Children
Secondary School Membership
None
1 Child
2 Children
3 Children
4 Children
Third Level Education Membership
None
1 Member
2 Members
3 Members
4 Members
Adult Unwaged Membership
None
1 Member
2 Members
3 Members
4 Members
Adult Membership
None
1 Member
2 Members
3 Members
4 Members
Parents Information
Parents Name
(Required)
Parents Phone No.
(Required)
Parents Email
(Required)
1st Players Details
Players Name
(Required)
First
Last
Players Date of Birth
MM slash DD slash YYYY
Player 1 Membership
(Required)
Please choose the membership for this player.
Primary School
Secondary School
Third Level Education
Adult Unwaged
Adult
Players Year in school as of September 2024
(Required)
Please Select..
1st Class
2nd class
3rd class
4th class
5th class
6th class
1st year
2nd year
3rd year
Transition year/4th year
5th year
6th year
Players Mobile (enter 0000 if the player is in school)
(Required)
Players Email
(Required)
Players Address
Street Address
Address Line 2
City
County
Eircode
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
1st Players Medical Information
Do you have any of the Following?
Asthma
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Epilepsy
(Required)
Yes
No
Fainting
(Required)
Yes
No
Are there any medical condition(s) or allergies that we should be aware of?
If there is a likelihood that you will be bringing medication* to training/matches please provide details of this ( *no medication will be administered without detailed instructions)
1st Players Emergency Contact
Emergency Contact Name
(Required)
Relations To Player
(Required)
Emergency Contact Number (Mobile Only Please)
(Required)
1st Players Consent
Consent
(Required)
I consider myself to be in good health and capable of taking part in hockey. I have completed the medical details and consent that, in the event of any illness/accident, any necessary treatment can be administered to me, which may include the use of anaesthetics.
I understand and accept this statement
(Required)
Consent
(Required)
I understand that players MUST wear gum shields and shin pads for their own protection and safety. Whilst all Wexford Hockey Club coaches and helpers will take every precaution to ensure that sessions are run safely, they cannot be held responsible for any loss, damage or injury suffered to me. Players turning up to training without gum shields and shin pads play at their own risk.
I understand and accept this statement
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
Yes I consent
No I do not consent
Consent
(Required)
Do you sign up to all elements of Wexford Hockey Club Code of Conduct
I agree to abide by the responsibilities of every member, to abide by the conduct expected of every player and club member, to abide by the personal pledges and to support and safeguard our younger players
Yes, I sign up to all elements of Wexford Hockey Club’s Code of Conduct
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
Yes I consent
No I do not consent
2nd Players Details
Players Name
(Required)
First
Last
Players Date of Birth
MM slash DD slash YYYY
Player 2 Membership
(Required)
Please choose the membership for this player.
Primary School
Secondary School
Third Level Education
Adult Unwaged
Adult
Players Year in school as of September 2024
(Required)
Please Select..
1st Class
2nd class
3rd class
4th class
5th class
6th class
1st year
2nd year
3rd year
Transition year/4th year
5th year
6th year
Players Mobile(enter 0000 if the player is in school)
(Required)
Players Email
(Required)
Players Address
Street Address
Address Line 2
City
County
Eircode
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
2nd Players Medical Information
Do you have any of the Following?
Asthma
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Epilepsy
(Required)
Yes
No
Fainting
(Required)
Yes
No
Are there any medical condition(s) or allergies that we should be aware of?
If there is a likelihood that you will be bringing medication* to training/matches please provide details of this ( *no medication will be administered without detailed instructions)
2nd Players Emergency Contact
Emergency Contact Name
(Required)
Relations To Player
(Required)
Emergency Contact Number (Mobile Only Please)
(Required)
2nd Players Consent
Consent
(Required)
I consider myself to be in good health and capable of taking part in hockey. I have completed the medical details and consent that, in the event of any illness/accident, any necessary treatment can be administered to me, which may include the use of anaesthetics.
I understand and accept this statement
(Required)
Consent
(Required)
I understand that players MUST wear gum shields and shin pads for their own protection and safety. Whilst all Wexford Hockey Club coaches and helpers will take every precaution to ensure that sessions are run safely, they cannot be held responsible for any loss, damage or injury suffered to me. Players turning up to training without gum shields and shin pads play at their own risk.
I understand and accept this statement
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
Yes I consent
No I do not consent
Consent
(Required)
Do you sign up to all elements of Wexford Hockey Club Code of Conduct
I agree to abide by the responsibilities of every member, to abide by the conduct expected of every player and club member, to abide by the personal pledges and to support and safeguard our younger players
Yes, I sign up to all elements of Wexford Hockey Club’s Code of Conduct
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
Yes I consent
No I do not consent
3rd Players Details
Players Name
(Required)
First
Last
Players Date of Birth
MM slash DD slash YYYY
Player 3 Membership
(Required)
Please choose the membership for this player.
Primary School
Secondary School
Third Level Education
Adult Unwaged
Adult
Players Year in school as of September 2024
(Required)
Please Select..
1st Class
2nd class
3rd class
4th class
5th class
6th class
1st year
2nd year
3rd year
Transition year/4th year
5th year
6th year
Players Mobile (enter 0000 if the player is in school)
(Required)
Players Email
(Required)
Players Address
Street Address
Address Line 2
City
County
Eircode
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
3rd Players Medical Information
Do you have any of the Following?
Asthma
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Epilepsy
(Required)
Yes
No
Fainting
(Required)
Yes
No
Are there any medical condition(s) or allergies that we should be aware of?
If there is a likelihood that you will be bringing medication* to training/matches please provide details of this ( *no medication will be administered without detailed instructions)
3rd Players Emergency Contact
Emergency Contact Name
(Required)
Emergency Contact Number (Mobile Only Please)
(Required)
Relations To Player
(Required)
3rd Players Consent
Consent
(Required)
I consider myself to be in good health and capable of taking part in hockey. I have completed the medical details and consent that, in the event of any illness/accident, any necessary treatment can be administered to me, which may include the use of anaesthetics.
I understand and accept this statement
(Required)
Consent
(Required)
I understand that players MUST wear gum shields and shin pads for their own protection and safety. Whilst all Wexford Hockey Club coaches and helpers will take every precaution to ensure that sessions are run safely, they cannot be held responsible for any loss, damage or injury suffered to me. Players turning up to training without gum shields and shin pads play at their own risk.
I understand and accept this statement
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
Yes I consent
No I do not consent
Consent
(Required)
Do you sign up to all elements of Wexford Hockey Club Code of Conduct
I agree to abide by the responsibilities of every member, to abide by the conduct expected of every player and club member, to abide by the personal pledges and to support and safeguard our younger players
Yes, I sign up to all elements of Wexford Hockey Club’s Code of Conduct
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
Yes I consent
No I do not consent
4th Players Details
Players Name
(Required)
First
Last
Players Date of Birth
MM slash DD slash YYYY
Player 4 Membership
(Required)
Please choose the membership for this player.
Primary School
Secondary School
Third Level Education
Adult Unwaged
Adult
Players Year in school as of September 2024
(Required)
Please Select..
1st Class
2nd class
3rd class
4th class
5th class
6th class
1st year
2nd year
3rd year
Transition year/4th year
5th year
6th year
Players Mobile (enter 0000 if the player is in school)
(Required)
Players Email
(Required)
Players Address
Street Address
Address Line 2
City
County
Eircode
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
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Mayotte
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Panama
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Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
4th Players Medical Information
Do you have any of the Following?
Asthma
(Required)
Yes
No
Diabetes
(Required)
Yes
No
Epilepsy
(Required)
Yes
No
Fainting
(Required)
Yes
No
Are there any medical condition(s) or allergies that we should be aware of?
If there is a likelihood that you will be bringing medication* to training/matches please provide details of this ( *no medication will be administered without detailed instructions)
4th Players Emergency Contact
Emergency Contact Name
(Required)
Emergency Contact Number (Mobile Only Please)
(Required)
Relations To Player
(Required)
4thPlayers Consent
Consent
(Required)
I consider myself to be in good health and capable of taking part in hockey. I have completed the medical details and consent that, in the event of any illness/accident, any necessary treatment can be administered to me, which may include the use of anaesthetics.
I understand and accept this statement
(Required)
Consent
(Required)
I understand that players MUST wear gum shields and shin pads for their own protection and safety. Whilst all Wexford Hockey Club coaches and helpers will take every precaution to ensure that sessions are run safely, they cannot be held responsible for any loss, damage or injury suffered to me. Players turning up to training without gum shields and shin pads play at their own risk.
I understand and accept this statement
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
(Required)
I am aware that photographs and video recordings may occasionally be taken for use in publicity material and on our website/social media and I agree that images of me may be used in this way.
Yes I consent
No I do not consent
Consent
(Required)
Do you sign up to all elements of Wexford Hockey Club Code of Conduct
I agree to abide by the responsibilities of every member, to abide by the conduct expected of every player and club member, to abide by the personal pledges and to support and safeguard our younger players
Yes, I sign up to all elements of Wexford Hockey Club’s Code of Conduct
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
(Required)
Do you consent to being added to any relevant WhatsApp Group(s) in relation to your involvement with Wexford Hockey Club? Please note: members can remove themselves from WhatsApp Groups at any stage
Yes I consent
No I do not consent
2 Full Membership Discount
Price:
2 Half Membership Discount
Price:
3 Full Membership Discount
Price:
3 Half Membership Discount
Price:
4 Full Membership Discount
Price:
4 Half Membership Discount
Price:
Total
Email
(Required)
Credit Card