GSWP Provincial Trials - Players 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)

Name:_________________________________________________________

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

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)

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:_____________________________________________________________

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:_____________________________

Cell/tel 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:___________________