Cycling Registration "*" indicates required fields 1Applicant Details2Sporting Achievement Details3Athlete Medical Form4Parent/Guardian Information5Agreements HiddenGroups* Cycling ** Do Not Delete **First Name* ** Do Not Delete **Family Name* ** Do Not Delete **Email* Enter Email Confirm Email ** Do Not Delete **Street Address* ** Do Not Delete **Town* ** Do Not Delete **Postcode* ** Do Not Delete **Date of Birth* MM slash DD slash YYYY ** Do Not Delete **Gender* Male Female Gender Neutral Home Phone Mobile Phone* (athlete)ATSI-Diverse Background (Optional): Yes No Are you of Aboriginal and Torres Strait Island background? This information is used for NCAS and NSW Government - Office of Sport reporting requirementsCALD - Culturally and Linguistically Diverse (Optional): Yes No Are you of a culturally or linguistically diverse background? This information is used for NCAS and NSW Government – Office of Sport reporting requirementsSchool* Home Club & Association* Membership Number* e.g. Netball NSW / Basketball NSW / Golf Link etc.Playing Positions Height* (cm) Sporting Achievement DetailsBest Achievements over the Past 12 Months Relating to the sport you are applying for SUMMARY OF RESULTS (Be accurate, as results will be checked by selection committee) NationalStateRegionalZoneClubSummary of Other Performances & Representations (Selections/Awards/Squad Invites)NationalStateRegionalZoneClubList what you or your coach would say are your specific strengths as an athlete of the sport you are applying for:List your specific weaknesses as an athlete of the sport you are applying for that you hope to improve: Athlete Medical FormComplete the medical information below. Complete the medical information below. NCAS treats this information as confidential and is bound by its privacy policy. NCAS will only distribute this information to those people whom we consider need it to ensure your health and well-being at NCAS events. The medical information provided within this document will be used throughout the associated NCAS Trials and subsequent Program should the athlete be accepted. Please contact NCAS as soon as possible if athlete medical information changes. Medicare Number* Do you have private medical cover?* Yes No If yes, state provider and policy numberDo you have ambulance cover?* Yes No Date of last tetanus injection DD slash MM slash YYYY Blood type*Please chooseDon't knowO negativeO positiveA negativeA positiveB negativeB positiveAB negativeAB positiveDo you suffer from asthma?* Yes No If yes, detail your asthma treatment planDo you suffer from diabetes?* Yes No If yes, detail your diabetes treatment planDo you suffer from epilepsy or similar episodes?* Yes No If yes, detail your epilepsy, or other treatment planDo you suffer from allergies (foods, medications, stings etc)?*Detail below please.Do you have any specific food requirements (gluten free, vegetarian, vegan etc) Yes No If yes, detail your specific food requirements below:List any other personal medications and the reasons for their use.List all other medical / health related matter/s not already mentioned that NCAS should be made aware of as well their related treatment plan/sDetails all significant injuries and treatments over the past 12 months. Parent/Guardian InformationParent/Guardian 1Parent/Guardian 1 Name* Parent/Guardian 1 Phone* Parent/Guardian 1 Email* Parent/Guardian 2Parent/Guardian 2 Name* Parent/Guardian 2 Phone* Parent/Guardian 2 Email* Other Emergency ContactsOther Emergency Contact People & Contact Number Athlete Declaration & Parental/Guardian ConsentAthlete Declaration* The information I have provided is accurate and correct Parental/Guardian Consent* I confirm that my child is fit to participate and give my consent for my child to apply and/or trial for an NCAS Program: Athlete Agreement* By completing and signing the Athlete Agreement, you are confirming your participation in the NCAS Program including attendance at all scheduled program events. PhoneThis field is for validation purposes and should be left unchanged.
