Table Tennis Interstate

SSWA Interstate Team*

Please 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 Details

Name*

First Last

Preferred first name (If different from above)

Date of Birth*

Gender*

Male
Female

Full School Name*

Home Postal Address*

Street Number and Name

Suburb*

Post Code*

Home Telephone Number*

Student Mobile Number*

Student Email*

Enter Email Confirm Email

Are you an Aboriginal or Torres Strait Islander?*

Yes
No

Parent/Guardian 1 Details

Name*

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 Address

Suburb*

Post Code*

Home Telephone Number*

Parent 1 Email*

Enter Email Confirm Email

Occupation*

Parent/Guardian 2 Details

Name

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 Address

Suburb*

Post Code*

Home Telephone Number*

Parent 2 Email

Enter Email Confirm Email

Occupation

Medical Information

Medicare 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*

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 Details

Is 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 Consent

In 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 required

Dietary Requirements

Does your child have any special dietary requirements.*

Yes
No

Please indicate the special dietary requirements.*

Additional Information

Please 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 Authority

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. 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 Swimminer
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 Options

Please consider your travel options carefully and indicate your selection below.

Travel Option*

Option 1 - SSWA will organise all aspects of flight travel
Option 2 - Parents will organise all aspects of flight travel ($50 cancellation fee applicable)
Home Championship

Departure Airline

Departure Date from Perth

Flight number

Departure time from Perth

:

Return Airline

Departure Date from Destination

Flight number

Departure Time from Destination

:

Escort Details*

My child will travel with a parent/guardian
My child will travel with an adult other than a parent/guardian
My child will travel on the same flight as the team
My child will travel independently

Name of adult

First Last

Relationship to Student

Mobile Number

Name of adult escorting my child to the airport on departure from Perth

First Last

Mobile Number

Name of adult escorting my child to the airport on departure from the interstate venue

First Last

Mobile Number

Accommodation Options

Please consider your accommodation options carefully and indicate your selection below.

Please select*

Option A - My child will stay in team accommodation organised by SSWA
Option B - My child will stay in privately arranged accommodation organised by parents

Name of the person the student will be accommodated with*

First Last

Mobile phone number of person the student will be accommodated with*

Name & Address of the accommodation*

Phone number at the accommodation*

Transport Arrangments

A transport levy will be charged to cover the cost of vehicles at the destination.

To opt out of the transport option please click below

I have arranged all of my child's transport and will not be using the team vehicles

Media Contact Permission

Prior 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

Upload Team Acceptance Form

Accepted 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 school.sport@education.wa.edu.au.

Untitled

Phone

This field is for validation purposes and should be left unchanged.

Student Details

Parent/Guardian 1 Details

Parent/Guardian 2 Details

Medical Information

Medication Details

Medication Consent

Dietary Requirements

Additional Information

Swimming Ability and Water Based Excursion Authority

Emergency Contact - Please provide an emergency contact, other than listed parents.

Travel Options

Accommodation Options

Transport Arrangments

Media Contact Permission

Contact us

phone

(08) 6318 5711

ADDRESS

TUART COLLEGE - 105 BANKSIA STREET, TUART HILL WA 6060

(ROOM A3 - HODGSON STREET ENTRANCE)

E-mail

school.sport@education.wa.edu.au