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Sport:  
Golf Handicap (if applicable):  
Lonestar:   Yes No
     
Athlete Information    
     
Firstname:*  
Surname:*  
Address:*  
Town:  
Postcode:  
Phone:*  
Athlete's Mobile:*  
Email:*  
     
School:*  
Date of Birth:*  
Height:*   cms
Weight:*   kgs
Gender:   Male Female
     
Medicare No:  
Fathers Name:  
Mothers Name:  
Parents Work Phone:   - Father
    - Mother
     
Injuries:   Please provide brief details of any recurring sports injuries in past two years
or recurring medical conditions and treatment
   
     
Emergency Contact:*  
Relationship:*  
Emergency Contact Phone:*  
Emergency Contact Mobile:  
     
Permission to call an ambulance in an emergency:   Yes No
Are you of Aboriginal or Torres Strait Islander Decent:   Yes No
Are you from a culturally diverse background:   Yes No


Athlete History

Current Association that you are registered with:  
Name of club or association coach:  
Phone No:  

Achievements in this Sport - (show highest level only - since 2006 only)

   
Year
   Highest Achievement
School:  
 
Regional:  
 
State:  
 
National:  
 


Other Sport - History & Achievements:

Other sports played:  
NIAS or other Academy squads:  
Other Representative achievements:  
Other specific sport information to support application:  


Declaration:

Athlete:
I am applying for a position in the NIAS 2010 program.
If selected, I agree to fulfill all obligations to the Academy Program.
 
 
Parent:
I have read and understand the info sheet for this program and give my
child/ward permission to apply for a position in the NIAS 2010 program.

 

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NIAS Major Partners

  
 
Northern Inland Academy of Sport (NIAS)
PO Box 907, Tamworth 2340 Australia Tel 02 6766 2526 Email nias@nias.org.au

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