Interstate Online Registration SSWA Interstate Team*Please Select Your Sport Below15s Boys Netball15s Girls NetballSwimming 13-19Swimming 10-12DivingPlease complete this form using correct title case (upper and lower) Has the student been in an SSWA Interstate team previously?* Yes No Will you be purchasing any uniform?* Yes No Student DetailsName* First Last Preferred first name (If different from above) Date of Birth* Day Month Year Gender* Male Female Full School Name* Home Postal Address* Street Number and NameSuburb* Post Code* Home Telephone Number Student Mobile Number* Student Email* Enter Email Confirm Email Does this student identify as Aboriginal and/or Torres Strait Islander?* Yes No Does the student speak a language other than English at home?* No Yes Was the student or a parent born overseas?* No Yes Please advise where they were born.* Does this student have any identified disabilities? (Physical, Intellectual, Transplant Recipient.) Yes No Parent/Guardian 1 DetailsName* First Last Relationship to Student* Parent 1 Mobile* Is Parent 1 Home Postal Address the same as the Student Home Postal Address Above?* Yes No Address* Street AddressSuburb* Post Code* Home Telephone Number Parent 1 Email* Enter Email Confirm Email Occupation* Parent/Guardian 2 DetailsName First Last Relationship to Student Parent 2 Mobile Is Parent 2 Home Postal Address the same as the Student Home Postal Address Above?* Yes No Address* Street AddressSuburb* Post Code* Home Telephone Number Parent 2 Email Enter Email Confirm Email Occupation Medical InformationMedicare Number* Do you have Private Health cover?* Yes No Name of Health Fund* Member Number* Does your child have any known allergies?* Yes No Please indicate the type of allergy* Select All Penicillin Other Drug Food Other Please provide details*Is your child subject to asthma, fainting, epilepsy, diabetes or any other condition that may affect his/her safety during this interstate experience?* Yes No Please provide details*Do you know the date of your child's last Tetanus injection?* Yes No Year of last Tetanus injection* Medication DetailsIs your child currently taking any medication.* Yes No Does your child self administer the medication.* Yes No Please provide details of the medication including type, dosage and frequency of use.*Medication ConsentIn the event your child sustains an injury or becomes ill, do you give permission for staff to administer the medication listed below?Analgesics containing paracetamol i.e. Panadol* Yes No Anti-Inflammatories containing Ibuprofen i.e Nurofen* Yes No Provide further information if requiredDietary RequirementsDoes your child have any special dietary requirements.* Yes No Please indicate the special dietary requirements.* Additional InformationPlease provide any additional medical or personal information that may enable the team management to provide better care for your child.Swimming Ability and Water Based Excursion AuthorityStudents may need to access swimming facilities for recovery or other sessions as indicated by coaches/managers. They will be fully supervised at all times. We need to be aware of your son/daughter's swimming ability.Permission is given for my son/daughter to participate in water based activities under the supervision of SSWA officials* Yes No Please indicate your child's swimming ability* Non Swimmer Weak Swimmer Competent Swimmer Strong Swimmer 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.*Emergency Contact - Please provide an emergency contact, other than listed parents.Name* First Last Home Phone Mobile* Relationship to Player* Travel OptionsPlease consider your travel options carefully and indicate your selection below.Travel Option* Option 1 - Parents will organise all aspects of flight travel and accommodation Option 2 - SSWA will organise all aspects of flight travel and accommodation Home Championship Travel Variation Pizzey Cup Please advise if you are orgnising your own Pizzey Cup flight/sChanges To Travel* I acknowledge that it is my responsibility to advise SSWA, in writing, of any changes to my selected travel arrangements. Media Contact PermissionPrior to travel we send a Media Release to the Local Community Newspapers. Please indicate below if you give us permission to provide Parent Number One's contact details to any Media Outlet that requests this information in order to publish an article.Do you give consent for parent number one's contact details to be passed on to media outlets, upon request?* Yes No Raffle Books* YES NO A maximum of 4 raffle books may be requested at a cost of $10 per raffle book. This cost will be added to your final invoice.Number of Raffle Books Requested1234Upload Team Acceptance FormAccepted file types: jpeg, jpg, pdf, doc, docx, Max. file size: 10 MB.The completed Team Acceptance Form can be uploaded here or emailed separately to [email protected].EmailThis field is for validation purposes and should be left unchanged.
