Jiwa Hockey
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Full Name *
Date of Birth *
State of Birth * Select StateJohorKedahKelantanMelakaNegeri SembilanPahangPerakPerlisPulau PinangSabahSarawakSelangorTerengganuWilayah Persekutuan Kuala LumpurWilayah Persekutuan LabuanWilayah Persekutuan PutrajayaOther / Outside Malaysia
Other State / Country of Birth *
Gender *
MaleFemale
Blood Group * Select Blood GroupA+A-B+B-AB+AB-O+O-
IC Number / Passport Number *
Residential Address *
Home Contact No
Mobile Contact No *
Email Address *
Name of School/ University *
Standard / Form / Course *
Emergency Contact Person *
Emergency Contact Number *
Medical History
Year Joining *
Insurance Policy *
YesNo
Note: Jersey name usually uses the player's first name.
Jersey Name *
Jersey Size * Select SizeXSSMLXL2XL3XL
Registration Fee
Registration Fee RM 100
Shirt Fee RM 70
Shipping Fee RM 10
Programme *
Monthly (4 Sessions)Monthly (5 or More Sessions)Beginner DevelopmentSchool Holiday CampGoal Keeper
Total Payment RM 175
* Registration fee, shirt fee and shipping fee are compulsory. All payments made are non-refundable.
I hereby confirm that all information provided is true and correct.
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