Winter SAMMNA M-League Nomination

Name(Required)

First Last

Date of Birth(Required)

Gender(Required)

Player Email(Required)

Player Mobile Number(Required)

Address(Required)

Street Address Suburb Postcode

Are you of Aboriginal and/or Torres Strait Islander origin?(Required)

Do you identify yourself as living with a disability/disabilities?(Required)

Please list the disability/disabilities you identify living with

Playing singlets will be available to loan from the club for 2024 winter season, what size would you prefer?(Required)

Please list short size in preparation for 2024/2025 season(Required)

Emergency Contact Name(Required)

First Last

Relationship to Player(Required)

Emergency Contact Mobile Number(Required)

Position #1(Required)

Position #2(Required)

Do you have any existing medical conditions/illness/allergies?(Required)

Please list your existing medical conditions/illnesses/allergies(Required)

Please note that all Winter Nomination Fees must be paid at time of nomination.

Processing fee

Nomination Fee(Required)

All Grades ($250)

Uniform Fee - Shorts(Required)

Shorts ($50)

Total

Credit Card(Required)

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Name

This field is for validation purposes and should be left unchanged.