Registration Form

SSWA Team Registration Code

SSWA Sporting Team

Has the student previously been in a SSWA Interstate Team?

No Yes

STUDENT DETAILS

Please ensure names indicted are as per birth certificate [for flight and accommodation bookings]

First Name

Surname

Preferred first name [if different]

DOB[dd/mm/yyyy]

House # & Street Name

Suburb

Postcode

Home Phone

School/TAFE attending

Year of Study

Student Mobile

Gender

Male Female

Student Email

Are you an Aboriginal or Torres Strait Islander?

No Yes

Given Name

Surname

Relationship to student

Mobile

Street

Suburb

Postcode

Home Phone

Parent 1 Email

Occupation

Given Name

Surname

Relationship to student

Mobile

Street

Suburb

Postcode

Home Phone

Parent 1 Email

Occupation

Medicare Number:	Do you have Private Health Insurance?	Health Fund Name
Is your child subject to fainting, epilepsy, diabetes or any other condition that may affect his/her safety during the interstate experience?
If so please provide details:
Is your child allergic to any of the following?
Penicillin	Any other Drug	Any Food	Other
Please provide details of any allergies indicated above:
Date of last tetanus injection
Parents/guardians are requested to make arrangements with the team manager for the safekeeping and handling of medications prior to the interstate trip. Is your child presently taking tablets or any other forms of medication
Does your child self administer the medication (Yes/No)
If yes please state the name of the medication, dosage and frequency of use
Any other information your manager should know?	Please provide any additional medical or personal information that may enable the team management to provide better care for your child.
Please indicate if you son/daughter has any special dietary requirements:
EMERGENCY CONTACT - Person to contact in case of emergency, injury or illness: (other than listed parent(s))
Name	Address
Home Phone	Mobile	Relationship to Player

Please consider your travel option carefully and indicate your selection. Please tick your option in the box.

For players choosing option 2 please provide your flight details:
Airline			Please list flight numbers below in this format [QF785/DJ291/JQ237 etc]
Depart form Perth	Date	Flight Number(s)		Depart from Perth Time [24hr clock]	Arrive at destination Time [24hr clock]
Return to Perth	Date	Flight Number(s)		Depart for Perth Time [24hr clock]	Arrive at Perth Time [24hr clock]
I will be travelling to and from the event with my parents			If NO, please indicate who the student will travel with?
For students travelling independently please provide the following details:
Name of adult escorting my child to the airport on departure from Perth				Contact Phone Number
Name of adult escorting my child to the airport on departure from interstate venue				Contact Phone Number

Please be aware that it is the responsibility of the parents to arrange transport to and from the venue and airport with Option B

Students may need to access swimming facilities for recovery or other sessions as indicated by coaches/managers. They will be fully supervised at all times. This form is to make our staff aware of your son or daughter’s swimming ability.

Permission is given for my son/daughter to participate in water based activities under the supervision of SSWA officials

SWIMMING ABILITY (refer to DET Swimming & Water Safety Continuum)

Stages

1. Beginner	4. Water Awareness	7. Intermediate
2. Water Discovery *	5. Water Sense *	8. Water Wise *
3. Preliminary	6. Junior	9. Senior

* Royal Life Saving Society of Australia awards.

My child has achieved Stage #

Date Achieved

I am unsure of my child’s swimming ability.

Please detail your assessment of your child’s skills and abilities in relation to the aquatic activities?

When you submit this form it will automatically be emailed to the School Sport WA Office:

Interstate Team Registration Form 2012