Interstate Online Registration SSWA Interstate Team*Please Select Your Sport BelowNetball 12s GirlsCricket 12s BoysCricket 12s GirlsTennis 12sTouch 12sTouch 15sGolf 12sGolf 18sFootball 12sPlease 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 - SSWA will organise all aspects of flight travel Option 2 - Parents will organise all aspects of flight travel ($50 cancellation fee may apply) Home Championship Changes To Travel* I acknowledge that it is my responsibility to advise SSWA, in writing, of any changes to my selected travel arrangements. Departure AirlinePlease selectQANTASJetstarVirginTigerDeparture Date from Perth Day Month Year Flight number Departure time from Perth : Hours Minutes AM PM AM/PM Return AirlinePlease selectQANTASJetstarVirginTigerDeparture Date from Destination Day Month Year Flight number Departure Time from Destination : Hours Minutes AM PM AM/PM 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 OptionsPlease consider your accommodation options carefully and indicate your selection below. Please select* Option A - My child will stay in privately arranged accommodation organised by parents Option B - My child will stay in team accommodation organised by SSWA Home Championship 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* 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 Upload 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].PhoneThis field is for validation purposes and should be left unchanged.
