Netball Umpire Application Form 2024/25

Netball Umpire Nomination Form 2024/25
Applications close on Monday 14th October.

For further information or queries please contact the NIAS Office on 02 6766 2526 or email admin@nias.org.au

Athlete Information
Name*

First NameLast Name
Birthdate*

DayMonthYear
Date
Gender*
Are you of Aboriginal or Torres Strait Islander Descent*
Athlete Email*
example@example.com
Athlete Mobile Number
Please enter a valid phone number.
Address*

Street Address

Street Address 2

TownState

Postcode
Council LGA*
School*
e.g. Tamworth Public or Oxley High
Shirt size*

Parent/Guardian Contact Details
Parent Name*

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

First NameLast Name
Second Parent Phone Number
Please enter a valid phone number.
Second Parent Email
example@example.com
I give permission for my child to be photographed at NIAS activities for promotional purposes*

I give permissionI do not give permission

Medical Details
Emergency Contact*

First NameLast Name
Emergency Contact Mobile Phone Number*
Please enter a valid phone number.
Permission to call ambulance?*
Medicare No.*
Private Health Fund Name (If applicable)
Fund Member Number
Do you have ambulance cover with private health?

YesNo
Do you have any medical conditions?*
If yes, please specify.
Do you have any ongoing/chronic injuries?*

Sport Information
Current Club/Association*
Current Badge Level*
How long have you umpired for?*
What are your sporting goals?*
Please upload a letter of recommendation from a current coach and/or PE teacher. *

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Please verify that you are human*
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