Application for Special Circumstance

Application for Special Circumstance

SA Country Championships
Name of person filling out Form*

First NameLast Name
Email*
example@example.com
I am an authorised Club/Association member

NoYes
Position held at Club/Association*
Association admin
Name of athlete applying for special circumstance within this application.*
John Smith
Date of Birth of athlete*

DayMonthYear
01-01-1990
To the Country Champs Sub-Committee,
SA Country Basketball Council Inc

I, First Name* Last Name* of Name of Club/ Association* , do hereby apply for special circumstance consideration to allow First Name* Last Name* to participate in the 2025 Country Championships:
Specify what you are applying for:*
Please state below the reasons why this consideration should be approved.*
Signature*

Clear
Date*

DayMonthYear
Date
Should be Empty: