FOOTBALL // WEBSITE APPLICATION

NIAS FC Selections

Registration form
Applications open & close Sunday 29 October 2023.

For further information please contact the NIAS office on 6766 2526 or email td@nias.org.au

Selections will only be held for SAP, JDL & PYL Programs.

SAP | DOB 2012-2015
JDL | DOB 2012-2014
PYL | DOB 2006-2011

Athletes are required to attend at least 1 selection event to be considered for 2024 (TBC).

Thursday 2 November - Rologas Sporting Field Armidale
Sunday 5 November - Gipps Street Sporting Fields Tamworth
Thursday 9 November - Gunnedah
Thursday 16 November - Gipps Street Sporting Fields Tamworth

Athlete Information
Athlete name*

First NameLast Name
Program to be considered for*
Birthdate*

DayMonthYear
Date
Gender*
Athlete Email
example@example.com
Athlete's Mobile Phone
Please enter a valid phone number.
Are you of Aboriginal or Torres Strait Islander Descent*
Address*

Street Address

Street Address 2

TownState

Postcode
Local Government Area*
School*

Parent/Guardian Contact Details
Parent Name*

First NameLast Name
Parent Contact*
Please enter a valid phone number.
Parent Email*
example@example.com
Parent Name

First NameLast Name
Parent Contact
Please enter a valid phone number.
Parent Email
example@example.com

Medical Details
Medicare No.*
Doctor Surgery
Do you have any injuries?*
Do you suffer from any known allergies?*
Permission to call ambulance?*
Emergency Contact*

NameContact Number
Private Health Fund Name
Fund Member Number
Do you have ambulance cover with private health?
Any medications?*
If yes, please specify.
Any medical conditions?*
If yes, please specify.

Sport Information
Current Club/Association*
Coach Name & Contact
Level of Competition/Representation
Result
How long have you played/competed?*
Preferred position*
What are your goals with your sport?*
Any additional information?

Declarations
Athlete & Parent Declaration*
Please verify that you are human*
Should be Empty: