NSWIS Emerging Talent Squad Nomination Form Survey

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1. Name

Name

*
2. Gender

Gender Male

Female

*
3. Date of Birth (dd/mm/yyyy)

Date of Birth (dd/mm/yyyy)

*
4. Age

Age

*
5. Contact phone number

Contact phone number

6. Mobile phone number

Mobile phone number

*
7. E-Mail

E-Mail

*
8. Sport

Sport

Please enter the details of your best sporting result in the last 12 months. Please include the date of the competition, event, distance,time, result and any other applicable information

*
9. Sporting results details

Sporting results details Date
Event
Distance (Individual athletes only)
Time (Individual athletes only)
Result
Highest Team representation
Other Applicable Information

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10. Do You Hold a Scholarship with any other Regional Academy or State Institute?

Do You Hold a Scholarship with any other Regional Academy or State Institute? Yes

No

11. If you answered Yes to Question 10 please provide the details.

If you answered Yes to Question 10 please provide the details.

NSWIS Emerging Talent Squad Nomination Form

1. Default Section

*1. Name

*2. Gender

*3. Date of Birth (dd/mm/yyyy)

*4. Age

*5. Contact phone number