Entry Form

GSWP PROVINCIAL TRIALS – PLAYERS ENTRY FORM

(Updated 11 February 2009, all information is treated as highly private and will not be given to any thrid parties)

PLEASE CIRCLE / HIGHLIGHT ONLY ONE OPTION IN EACH ROW (Questions 1 - 16):
DO NOT LEAVE ANY UNANSWERED QUESTIONS OR SPACES!

Name:_____________________________________________________________

1) I am a: Male Female

2) I was born in: 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

3) I am trying out for the following provincial side: U/13 U/14 U/16 U/19

4) My 1st choice position is: centre forward centre back wing driver keeper

5) My 2nd choice position is: centre forward centre back wing driver keeper

6) I have been selected for a provincial water polo side before: None B side A Side

7) I have played for a provincial team for the following years: 0 1 2 3 4 5

8) I am of the following ethnicity: White Black Coloured Indian Chinese Other

9) I play for a Gauteng Club side: yes no

10) I am registered with SwimSA through my: swimming club water polo club school

11) I have paid my trials fee by: cash electronic transfer cheque

12) I have paid my trial fee to:

Mr G Ramsey Ms F. Cullen Ms L. Gilbert Mr B. Webster Ms J Samson

Another Person:(please state name) _____________________________________________________

13) This entry was handed in on the following date_____________ and is: early late

14) I have paid in: R50 R150

15) I understand that I will be expected to doing fund raising via a raffle yes

16) My parent/s would like to be involved in the following Provincial activities below yes no

(poolside catering) (fund raising) (serve on the LOC) (offer their expertees)

(sponsor raffle prize) (act as team manager/es) (place an advert in the programme)

(poolside sales) (serve on the GSWP staff) (help in some other way)


PERSONAL INFORMATION PLEASE PRINT THE INFORMATION BELOW IN CAPITAL BLOCK LETTERS:

PLAYER:
Surname:___________________________________________________(NB check spelling!)

Full Name:__________________________________________________ (NB check spelling!)

Date of Birth:__________________________ Player cellular:_________________________

Player email:__________________________

PARENTS:
Residential Address:_________________________________________________________
Postal Address (Domicile):____________________________________________________
Cell Number Father:__________________________________________________________
Cell Number Mother:_________________________________________________________

E-mail Father:______________________________________________________________

E-Mail Mother:______________________________________________________________
Fax number:________________________________________________________________


SCHOOL:
Name of School:_____________________________________________________________
Tel number of school:_________________________________________________________
Fax number of school:________________________________________________________
E-mail address of school:______________________________________________________
Name of school coach:________________________________________________________
Cell of school coach:__________________________________________________________

MEDICAL:
Name of medical aid:_________________________________________
Medical aid number: __________________________________________
Tel number of medical aid (emergency authorization)__________________

Allergies:__________________________________________________________________

Dietary requirements:________________________________________________________

Important Medical info:_______________________________________________________

Name of family doctor:_____________________ Contact Nr. of family doctor:__________________

ADMIN (to be completed by GSWP)
Amount paid to GSWP: R50 R150
Proof of payment received: yes no
GSWP Person who received payment:_____________________
Player Trials number allocated:___________________