RSA Exemption Request Form

Exemption Request Form
This form must be completed for all exemption requests.

Please note: A medical certificate will be required to ensure that a medical exemption is approved if the event is a mandatory Event Requirement.

The exemption form must be submitted prior to the event that will be affected.
Supporting Documentation (e.g. Medical Certificate)

Cancelof
Athlete Information
Name of athlete*

First NameLast Name
Contact Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Coach Information
Name of coach*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Exemption Request
Is this a Medical exemption (ME) request*

YesNo
Practitioner Information
Practitioner Name*

First NameLast Name
Medical Discipline*
Practitioner Contact Phone Number*
Please enter a valid phone number.
Injury / Illness Data
Date of intial presentation*

DayMonthYear
Date
Date of consult*

DayMonthYear
Date
Diagnosis*
Type of report*
Nature of report*
Type of injury / illness*
Cause of injury / illness*
If cause of injury or illness not listed, please specify below*
Treatment Required
Imaging Required

X-rayCTMRIBone ScanUltrasoundOther
On water training status*

FullModifiedNoOther
Required*

PhysiotherapyMedicalSpecialist
If modified, please outline restrictions*
Prognosis
Expected Date to Return to Full Training*

DayMonthYear
Date
Selection event *
Please list the selection event that will be effected
Exemption request - non medical
Reason for exemption*

Personal reasonsPrevious committmentSchool campClub training camp
Name of School*
Please provide as much information as possible for the exemption to be considered*
Thank you for your exemption request.

The State Team Selection Panel are approving all requests from school athletes with conflicting camp commitments that will effect attendance at this mandatory event.
Should be Empty:

Exemption Request Form

Athlete Information

Coach Information

Exemption Request

Practitioner Information

Injury / Illness Data

Treatment Required

Prognosis

Exemption request - non medical