2021 AJBVC Trial Nomination Form

Trial Information:

Date: Sunday 13 December, 2020

Times:

8:00am - 10:00am = u14 & u15 Boys & Girls
10:00am - 12:00pm = u16, u17 & u18 Boys & Girls

Price:

$30.00 per athlete (if registered by noon Friday 11 Dec);
$40 late registrations

Venue: Sandstorm Beach Club, 590 Mains Rd, Nathan

Please note:

Athletes trial as individuals, not as teams
2021 Age Groups are listed below
All participants must be VQ members

If you would like to be considered for QLD's 2021 AJBVC teams, please provide the requested information below.

Athlete's Name *

Given Name Surname

Gender *

Date of Birth *

Day Month Year

I am a current VQ Member *

Yes No

VQ ID.

Last year played in a Volleyball Queensland Team

Division *

U14 (born 2008, and later) U15 (born 2007) U16 (born 2006) U17 (born 2005) U18 (born 2004)

Attending Trials *

I will be attending trials I am unable to attend trials

Please say why you are unable to attend trials

You will be invited to attend a team training in lieu of trials

All information provided to Volleyball Queensland will be treated as confidential. Please contact our Events Manager, Damien Searle, if you wish to discuss this in greater detail.

Athlete Contact Details:

Address *

Street Address

Street Address Line 2

Suburb State

Post Code Country

Mobile Number *

Home Phone Number

E-mail Address *

Parent/Guardian Contact Details:

First Parent/Guardian's Name *

Given Name Surname

Mobile Number *

Home Phone Number

Work Phone Number

FPG E-mail Address *

Second Parent/Guardian's Name

Given Name Surname

Mobile Number

Home Phone Number

Work Phone Number

SPG E-mail Address

Emergency Contact *

You may have another adult that you want us to contact (e.g. grand parent) should you be unavailable in the event of an emergency.

Emergency Contact Name

Given Name Surname

Mobile Number

Relationship to Athlete/s

Medical History and Authority:

Does your child have special dietary requirements? *

Details of special dietary requirements *

Does your child have a medical condition that we need to be aware of? *

Details of Medical Condition *

Does your child have an existing sports injury that we need to be aware of? *

Details of Sports Injury *

Does your child suffer from any injury or condition which is likely to be aggravated by the team/squad activities? *

Details of Injury/Condition *

Does your child have an allergy? *

Treatment for Allergy *

Does your child suffer from asthma? *

Is the asthma controlled? *

Details of Asthma Medication *

Does your child currently take any other medication? *

Details of Additional Medication *

Does your child have their own Medicare card? *

Card Holder's Name *

First Name Last Name

Medicare Card Number *

Additional Health Insurance Company

Membership Number

Cover Provided

Athlete Agreement *

I have read the Athlete’s Code of Conduct and understand its contents and conditions. I accept the responsibilities contained therein and swear to abide by them during all Queensland representative team commitments.

Parent/Guardian Consent and Authorisation *

I have read and accept the terms outlined in the State Teams Parent/Guardian Authorisation on the VQ website.

Payment *

2021 AJBVC Trial fee $ 30.00 AUD

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

VQ code

Office only