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WRAS Harness Racing Program
Date - Monday 23 October 2017
nomination form
Driver's personal details
First name *
Your answer
Surname *
Your answer
Date of birth *
Your answer
Gender *
Email *
ALL correspondence regarding the program will be sent to the email address you provide
Your answer
Address *
Your answer
Town *
Your answer
Postcode *
Your answer
Current school year *
Your answer
Current school *
Your answer
Are you of Aboriginal or Torres Strait Islander decent? *
(for statistical purposes could you please answer)
Do you have a disability? *
(for statistical purposes could you please answer)
Please read the 'WRAS 2018 uniform items and available sizes' document in the 'downloads' section of the WRAS website. What size polo shirt do you require? Sizes come in kids, womens and mens
Your answer
Medicare number *
Please ensure all 10 digits are included
Your answer
Position on card *
Your answer
Valid to *
Your answer
Do you have any medical conditions that WRAS should know about? *
Declaration and authority
I give permission to the staff at the WRAS Harness Education session for my child/ward to be treated in the event of illness or accident. I also undertake to pay all costs (eg ambulance travel), medical fees and/or cost of necessary medication which may be incurred whilst my child/ward is in the care of the Western Region Academy of Sport. I understand that I will be contacted as soon as possible should medical assistance be needed for my child.
*
Name of parent/guardian *
Your answer
Phone number of parent/guardian *
Your answer
Email of parent/guardian *
Your answer
By submitting this form to WRAS the athlete
makes the following declaration:
I am applying for a position in the WRAS Harness program. I understand the education sessions will be held on November 25th 2017, December 16th 2017 and February 3rd 2018. If selected I will fulfil all obligations of the WRAS program.
*
By submitting this form to WRAS the parent/guardian
makes the following declaration:
I have read and understand the information and give my child/ward permission to apply for a position in the WRAS 2017 harness program.
*
Enrolments close 9am on Friday 10 November 2017
The WRAS office must receive the enrolment form by the closing date. All enrolments will be notified by email.
For further information please contact Tanya Pallier, WRAS Office Manager by phone 6338 4821 or email tpallier@csu.edu.au
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