SCHOOL SPORT WA

PO Box 8224, Perth Business Centre, WA 6849 ABN: 25 492 318 440 school.sport@education.wa.edu.au

Reproduction of the SSWA website in whole or part for educational purposes, within an educational institution and on condition that they are not offered for sale, is permitted.

Triathlon

Interstate Nomination Form 2012

It is important all the information on this form is completed in full and submitted on the button at the bottom of the page.

School

Name:

Address:

Suburb: Post Code:

Phone: Fax:

Nominee Contact Details

Surname:

First Name:

Email Address:

Mobile No: Home Phone:

DOB:

Home Address:

Current Club:

Current Coach:

Coach Contact:

Family Contact Details

Parent / Guardian First Name:

Surname:

Address (if different from above):

Email Address:

Mobile No: Home Phone:

Principal Authority:

A condition of participation is schools compliance with Department of Education Policies and Guidelines as they relate to excursions. My school Principal is aware of, and endorses, this nomination. Click Here to view Principal/Parent Risk Management Plan.

Yes (Please click)

Principal's Signature:____________________________________

A copy of this form with Principal's Signature must be brought to the event if trialling for the state team. For all other competitors, this is for your Principal's records only.

Nominations Due: Fri 11 November 2011 (No late nominations will be accepted!)

When you submit this form it will be emailed to the Sport Coordinator:

Stuart Denton

Duncraig SHS

stuart.denton@education.wa.edu.au

For your records please print a copy of the form before submitting