TRIATHLON // WEBSITE APPLICATION

NIAS Triathlon Program Application

Registration form
Applications open 14 July 2025 & close 3 August 2025

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

Athlete Information
Name*

First NameLast Name
Birthdate*

DayMonthYear
Date
Primary Email (Parent)*
example@example.com
Secondary Email (Athlete)*
example@example.com
Gender*
Are you of Aboriginal or Torres Strait Islander Descent*
Is English, your main language spoken at home?
Home Address*

Street Address

Street Address 2

TownState

Postcode
Council LGA*
Athlete's Mobile Phone*
Please enter a valid phone number.
Level of Schooling or equivalent*
School*
e.g. Tamworth Public or Oxley High

Parent/Guardian Contact Details
Parent Name*

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

First NameLast 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?*
Emergency Contact*

First NameLast 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?
Any medications?*
If yes, please specify.
Any medical/health conditions?*
If yes, please specify.

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