Northern Inland Academy of Sport (NIAS): Athlete Sport Application

ONLINE APPLICATION FORM FOR 2013 SPORT INTAKES

Athlete Information
Sport*
First Name*
Last Name*
Birthdate*
Email*
Gender*
ATSI
NESB
Height (cm)*
Weight (kg)*
Address*
City*
State*
Postcode*
Phone*
Athlete's Mobile*
School*

Parent/Guardian Contact Details
Fathers Name*
Fathers Phone Number*
Mothers Name*
Mothers Phone Number*
Parent Email*
Council LGA*

Medical Details
Medicare No*
Family Doctor
Family Doctor Ph Number
Do you have any injuries*
Permission to Call Ambulance*
Emergency Contact*
Emergency Mobile No*
Do you suffer from any known allergies?*
Member of Private health Fund
Fund Name
Fund Member Number
Medications*
Medical Operations/Conditions*
Ambulance Cover with Private Health

Sport Information
Lonestar Sport (if applicable)
Golf H'cap (if applicable)
Current Club/Association*
Coach Name
Coach Mobile
Level of Competition/Representation
Result
Level of Competition/Representation
Result
Level of Competition/Representation
Result
Additional Information
How long have you played/competed*
Preferred Position*
What are your goals with your sport*
Who is your favourite Athlete?*
Greatest Influence on your Sports career*

Declaration
Athlete declaration*
I am applying for a position into the Northern Inland Academy of Sport Talent Development Program. If selected, I agree to fulfill all obligations to the Academy Program.
Parent Declaration*
I have read and understand the information provided for this program and give my child/ward permission to apply for a position in the NIAS Program.

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