Exemption Request Form

Rowing SA Exemption Request Form

This form must be completed for all exemption requests.
Please note: All exemption requests must be made on this form and submitted before the affected event (for a mandatory regatta, before entries close). Medical exemptions need a medical certificate or a letter from a medical specialist.
Privacy collection notice: Rowing South Australia Inc. (Rowing SA) collects the personal information in this form, including any health information, to assess your exemption request, manage your participation in State Team selection activities safely, and contact you, your coach and, where needed, your treating practitioner. Your information will be used only for these purposes and disclosed only as needed to Rowing SA staff, the Selectors, the Selection Ombudsman, State Team coaches and team managers and, if an appeal is lodged, the Independent Appeals Tribunal. Your medical, personal and contact details will not be shared with other nominees. Rowing SA handles personal information in accordance with its Privacy Policy, available on the Rowing SA website. You can ask to access or correct your information by contacting Rowing SA at aswift@rowingsa.asn.au. If you do not provide the required information, Rowing SA may not be able to consider your exemption request.
Athlete Information
Name of athlete

First NameLast Name
Contact Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Email
example@example.com
Age
Exemption request - non medical
Reason for exemption
Name of School
Name of Club
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 affect attendance at mandatory events.
Team Details
What team are you trialling for?
Event and Date
Please refer to the event requirements for the team you are trialling for. These can be found on the Rowing SA website, under the State Teams menu.

List the event or activity, as per those event requirements, that you are seeking an exemption for, in the box below.
Event or activity you are seeking an exemption for (as listed in the Event Requirements)
Please specify the event or activity
Please provide the date/s of the mandatory event, for which this exemption is being requested
Parent / Guardian Information
Parent / Guardian Name

First NameLast Name
Parent / Guardian Email
example@example.com
I confirm I am the parent or guardian
Exemption Request
Is this a Medical exemption (ME) request
Supporting Information
Supporting Documentation (e.g. Medical Certificate)

Cancelof
Coach Information
Name of coach

First NameLast Name
Coach phone number
Please enter a valid phone number.Format: 0000 000 000.
Practitioner Information
Practitioner Name

First NameLast Name
Medical Discipline
Practitioner Contact Phone Number
Please enter a valid phone number.Format: 0000 000 000.
Injury / Illness Data
Date of initial presentation

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Date of consult

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
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

Other
On water training status

Other
Referral required
If modified, please outline restrictions
Prognosis
Expected Date to Return to Full Training

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Selection event
Please list the event that will be affected
I understand that exemptions are at the discretion of the Selectors, that an exemption does not guarantee selection, and that the Selectors may take into account the information available to them in making selection decisions.
I understand the Selectors will respond by email. If you have a concern about the outcome, the Appeals Policy sets out the steps
Thank you for your exemption request.
Should be Empty:

Rowing SA Exemption Request Form

Athlete Information

Exemption request - non medical

Team Details

Event and Date

Parent / Guardian Information

Exemption Request

Supporting Information

Coach Information

Practitioner Information

Injury / Illness Data

Treatment Required

Prognosis