Leave of Absence Request Form

1
State PSA* This field is required.Please select your State PSA in the state of your current residence
NSWPSA (incl. ACT)
VPSA (incl. TAS)
QPSA (incl. NT)
SAPSA
WAPSA
2
State PSA Registration Number* This field is required.Please contact your State PSA to confirm your registration number
3
Full Name* This field is required.As listed on Driver's licence or Passport or Working with Children clearance
First Name
Last Name
4
Date of Birth* This field is required.
Date
Day
Month
Year
5
Home Address* This field is required.
Street Address
Street Address Line 2
Suburb
Please Select
Please Select
NSW
QLD
VIC
ACT
SA
WA
TAS
NT
State
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Mobile Phone Number* This field is required.
7
Email* This field is required.Please type valid email address
example@example.com
Confirm Email
8
Your Accreditation Level* This field is required.Level 0 (Community) Level 1 (Development) Level 2 (Intermediate) Level 3 (Advanced) Level 4 (Senior) Level 5 (High Performance) Level 6 (Elite) Level 7 (Master)
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Free Skating
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Pairs
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Ice Dance
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Synchronised
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9
Working Venues* This field is required.I am conducting private, group, Learn to Skate/Aussie Skate lessons at the ice arena(s) below:
Huge
Large
Normal
Small
Ok
Ok
10
Commencement Date* This field is required.
Date
Year
Month
Day
11
I, {fullName} of {address} , hereby give notice of my intention to take a Leave of Absence from {statePsa}.

I understand that my annual membeship fees will be exempt for a 2 (two) year period only from {commencementDate}, when after such time if I have not returned as a member, I shall be deemed to have resigned.

After that time, any return to coaching will need to meet the requirements of APSA return to coaching policy.
12
Signature* This field is required.
Clear
Should be Empty: