Download P O Box 47, AINSLIE ACT 2602

AUSTRALIAN LITTLE ATHLETICS CHAMPIONSHIPS
20th - 24th April 2017
Sydney Olympic Park Athletics Centre
New South Wales
NOMINATION FORM
Under 13 and Under 15 athletes, this is your opportunity to represent the ACT at the
National level. Please complete and return this form to the ACT Little Athletics Office
PO Box 5094 Garran ACT 2605 or [email protected] by Monday 6th March
2017. Please mark clearly on the envelope or in the email subject
“Nomination Form – “Sydney”.
Please make sure you read the accompanying information sheet prior to
nominating!
ATHLETE’S NAME: …………………………………………………………………
AGE GROUP:
Circle one
U13
U15
Circle one
MALE
FEMALE
DOB ……../……../…………
REGISTRATION NO: …………….. CENTRE: ……………………………...
ATHLETE’S ADDRESS: …………………………………………………………...
…………………………………………………………………………………………..
PARENT’S NAME & PHONE NUMBER/S: ……………………………………..
…………………………………………………………………………………………
PARENT’S EMAIL ADDRESS: …………………………………………………...
Circle one
DO YOU HAVE YOUR OWN COACH:
YES
NO
If so, Coach’s name: ………………………………………………………………...
Coach’s contact details: Phone:………………Email:……………………………
Centre President Endorsement Signature:…………………………………….
Please note: There is a levy for selected athletes and the cost will be approximately $1,100 $1,300. This cost will cover all costs involved: transport, accommodation, uniform, food,
entertainment and sightseeing for 5 days. The ACT ALAC Team will be published on the
LAACT website on Wednesday 22nd March at 2.00pm. All selected athletes are required to
attend team training sessions during the 4 weeks prior to the championships. A compulsory
team meeting for selected athletes and parents will be on Thursday 24th March 2016
6.30pm at the Southern Cross Club Woden. An invoice will be issued to each family at the
meeting and a non-refundable $400.00 deposit must be paid before or on Tuesday 28th
March 2016.
SIGNATURE OF ATHLETE:…………………………………………Date:………..
NAME OF PARENT/GUARDIAN: …………………………………………………..
SIGNATURE OF PARENT/GUARDIAN: ………………………….Date:………..