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.
Team Details
InterstateMastersOceaniaPathway
Exemption 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.
Please provide the date/s of the mandatory event, for which this exemption is being requested*
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
Exemption Request
YesNo
Supporting Information
Supporting Documentation (e.g. Medical Certificate)

Cancelof
Coach Information
Name of coach*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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 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
X-rayCTMRIBone ScanUltrasoundOther
FullModifiedNoOther
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
Personal reasonsPrevious committmentSchool training campClub training campEvent/regatta cancelled or postponed
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 effect attendance at this mandatory event.
Should be Empty:

Exemption Request Form

Team Details

Exemption Date

Athlete Information

Exemption Request

Supporting Information

Coach Information

Practitioner Information

Injury / Illness Data

Treatment Required

Prognosis

Exemption request - non medical