<p> South East Region Netball Academy 2014 Squad Trials</p><p>2014 South East Region Netball Academy Squad (14-16 Years) Athlete Nomination Form</p><p>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)</p><p>ATHLETE DETAILS</p><p>Athlete Name: </p><p>Address: Suburb: </p><p>Council area I reside in: Postcode: </p><p>Date of Birth: </p><p>Home Phone: Mobile: </p><p>Email: </p><p>Are you an Australian Citizen? YES / NO </p><p>PARENT / GUARDIAN DETAILS</p><p>Parent / Guardian Name: </p><p>Home Phone: Mobile: </p><p>Emergency Contact Name: </p><p>(In case parent / guardian cannot be contacted) Phone: </p><p>Mobile: Their relationship to you: </p><p>ATHLETE PROFILE</p><p>Current Netball Association: </p><p>Height (cm): Playing Position/s: 1 2 </p><p>Current Playing Level (team & division): </p><p>COACH DETAILS</p><p>Current Coach: </p><p>Mobile: Email: </p><p>SPORT DETAILS Please detail your recent netball performance at Association, State, National and International competition, including dates. PageAssociation 1 of 2 www.netballnsw.com</p><p>South East Region Netball Academy 2014 Squad Trials</p><p>State (including NSWIS scholarships) & National Honours</p><p>Have you previously participated in the SERAS Netball Academy ‘15 Years’ or ‘Open Squad’ Program? If so, please specify which years:</p><p>Have you previously been selected in the Netball NSW Talented Athlete Program (TAP)? If so, please specify which years:</p><p>Other Honours:</p><p>Playing Style: Other Sports / Interests: Interesting Facts: Local Paper: </p><p>SPORTS INJURIES Have you sustained any injuries in the past two years: Yes / No</p><p>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): </p><p>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.</p><p>Signature of Athlete: Date: _ </p><p>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] </p><p>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. </p><p>Nominations close at 5pm on Monday 31 March 2014</p><p>Page 1 of 2 www.netballnsw.com</p>