Pathway State Team Nomination Form

Name*
First Last
Address*
Street Address Address Line 2 Suburb State Postal Code Country
Date of Birth*
DD slash MM slash YYYY
Phone*
Email*
Emergency contact full name*
First Last
Emergency contact phone number*
Medicare Number*
Information regarding injury / illness / medical
Please supply parent/guardian full name*
First Last
Please supply parent/guardian mobile number*
Please supply parent/guardian email address*
School*
Provide your best 2km ergo time within 1 January 2023 and date of nomination*
When was this ergo completed (date)*
DD slash MM slash YYYY
Who can verify this time?*
Name of coach*
First Last
Coach's email address*
Please nominate your preferred side or indicate if you intend to be a coxswain.*
I can competently row the other side (if asked by the STSP)*
Please indicate your first priority crew you would like to be considered for:*
(If a coxswain) please indicate your second priority crew you would like to be considered for:
As a nominated SA Pathway Athlete, I agree to conduct myself in accordance with (please tick):*
All Rowing SA Policies and Code of Conduct (www.rowingsa.asn.au)
https://rowingsa.asn.au/publications-and-policies/
I have read the Rowing SA State Selection Policy:*
Yes
https://rowingsa.asn.au/wp-content/uploads/2021/09/RSA-2022-Pathway-State-Team-Selection-Policy_FINAL_8.9.21-1.pdf
Dietary Requirements
Select all that apply*
- None
- Gluten Free
- Lactose Free
- Vegetarian / Vegan
- Nut Allergy
Other
Uniform Sizing
Zootie size*
T-shirt size*
Jumper size*
Short size*

Dietary Requirements