South East Region Netball Academy 2014 Squad Trials

2014 South East Region Netball Academy Squad (14-16 Years) Athlete Nomination Form

Please circle which trial date and venue you will be attending: Trial 1 – Wednesday 2nd April at Braidwood (Northern Trial) or Trial 2 – Thursday 3rd April at Bega (Southern Trial)

ATHLETE DETAILS

Athlete Name:

Address: Suburb:

Council area I reside in: Postcode:

Date of Birth:

Home Phone: Mobile:

Email:

Are you an Australian Citizen? YES / NO

PARENT / GUARDIAN DETAILS

Parent / Guardian Name:

Home Phone: Mobile:

Emergency Contact Name:

(In case parent / guardian cannot be contacted) Phone:

Mobile: Their relationship to you:

ATHLETE PROFILE

Current Netball Association:

Height (cm): Playing Position/s: 1 2

Current Playing Level (team & division):

COACH DETAILS

Current Coach:

Mobile: Email:

SPORT DETAILS Please detail your recent netball performance at Association, State, National and International competition, including dates. PageAssociation 1 of 2 www.netballnsw.com

South East Region Netball Academy 2014 Squad Trials

State (including NSWIS scholarships) & National Honours

Have you previously participated in the SERAS Netball Academy ‘15 Years’ or ‘Open Squad’ Program? If so, please specify which years:

Have you previously been selected in the Netball NSW Talented Athlete Program (TAP)? If so, please specify which years:

Other Honours:

Playing Style: Other Sports / Interests: Interesting Facts: Local Paper:

SPORTS INJURIES Have you sustained any injuries in the past two years: Yes / No

If yes, please list the following: type of injury (e.g. sprain, dislocation, tear, fracture) approximate date of injury and the treatment received (e.g. physiotherapy, surgery):

To the best of my knowledge, all information on this form is correct. Failure to disclose any relevant information may jeopardise your selection into the team.

Signature of Athlete: Date: _

Return completed form to: Dianne Brown – Coach Development and Regional Academy Coordinator - Netball NSW A: PO Box 396, Lidcombe NSW 1825 Ph: 02 9951 5013 Fax: 02 9951 5099 Email: [email protected]

You will receive a confirmation of receipt by email. If you do not receive the email within 2 working days of sending your application, please contact Netball NSW immediately.

Nominations close at 5pm on Monday 31 March 2014

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