NIAS Basketball Program Application
Registration form
Athlete Information
Name
*
First Name
Last Name
Birthdate
*
/
Day
/
Month
Year
Date
Primary Email (Parent)
*
example@example.com
Gender
*
Please Select
Male
Female
Non-Binary/Gender Fluid
Gender Identity not sufficiently represented
Are you of Aboriginal or Torres Strait Islander Descent
*
Please Select
Yes
No
Secondary Email (Athlete)
*
example@example.com
Home Address
*
Street Address
Street Address 2
Town
State
Postcode
Council LGA
*
Please Select
Armidale Dumaresq
Glen Innes Severn
Gunnedah
Gwydir
Inverell
Liverpool Plains
Moree Plains
Narrabri
Tamworth Regional
Tenterfield
Uralla
Walcha
Athlete's Mobile Phone
*
Please enter a valid phone number.
Level of schooling or equivalent
*
Please Select
Primary School
High School
School
*
e.g. Tamworth Public or Oxley High
Parent/Guardian Contact Details
Parent Name
*
First Name
Last Name
Parent Phone Number
*
Please enter a valid phone number.
Parent Name
First Name
Last Name
Parent Phone Number
Please enter a valid phone number.
Parent Email
example@example.com
Medical Details
Medicare No.
*
Do you have any ongoing/chronic injuries?
*
e.g. previous ACL reconstruction
Permission to call ambulance?
*
Please Select
Yes
No
Emergency Contact
*
First Name
Last Name
Emergency Mobile Phone Number
*
Please enter a valid phone number.
Do you suffer from any known allergies?
*
If yes, do you require an epipen?
Private health fund name (if applicable)
e.g. HCF
Fund Member Number
Do you have ambulance cover with private health?
Please Select
Yes
No
Any medications?
*
If yes, please specify.
Any medical conditions?
*
If yes, please specify.
Sport Information
Current Association
*
Current Club
*
Sports Reference
e.g. Coach name
Sports reference mobile &/or email
Highest Level of Competition/Representation
Please Select
School
Club
Regional
State
National
How long have you played/competed?
*
Preferred position
*
What are your sporting goals?
*
Any additional information?
Please verify that you are human
*
Parent & Athlete Declaration
Submit
Should be Empty: