Cross Country Secondary Champion Schools – Individual- Nomination Form

$12.00

$

Does the student attend a Secondary/High School? *

Yes

No they are in Primary School

Please nominate for the Primary Cross Country Event *

Primary Cross Country Product

Student First Name *

Student Surname *

Full School Name

I am home schooled

I acknowledge I will be charged an additional fee [+$10.00]

Suburb *

Student DOB *Students will be allocated to races based on their birth year.

Gender *

Male

Female

Athlete with a Disability *

Yes

No

Multi Class Classification *

Parent / Guardian First name *

Parent / Guardian Surname *

Parent Street Address *

Parent Suburb *

Parent Post Code *

Parent Email *

Parent Email confirm *

Parent Mobile *

Interstate Team - Do you wish to be considered for State team Selection? *

Yes (you do not need to complete any further nomination forms)

No

Permission to publish student name on SSWA website *

Yes

No

School Notification *

The school is aware of this nomination

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