(Updated June 2010, all information is treated as highly private and will not be given to any thrid parties)
(Boys entries can be email to ramseyg@stdavids.co.za)(Girls entries can be emailed to fiona.cullen@vodamail.co.za)
Name:_________________________________________________________
PLEASE CIRCLE / HIGHLIGHT ONLY ONE OPTION IN EACH ROW (Questions 1 - 14):
DO NOT LEAVE ANY UNANSWERED QUESTIONS OR SPACES!
1) I am a: Male Female
2) I was born in: 1992 1993 1994 1995 1996 1997 1998 1999
3) I am trying out for the following provincial side: U/13 U/14 U15 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 Name of club:_____________________
10) I am registered with Swim SA through my: swimming club water polo club school
11) I have paid my trials fee by: electronic transfer or cash on trial day (150)
NB! you are required to bring your proof of payment to the trials.
12) This entry was handed in on the following date_____________ and is: early late
13) I have paid in: R50 R150
PLEASE PRINT THE INFORMATION BELOW IN CAPITAL BLOCK LETTERS:
PLAYER:
Surname:______________________________________(NB check spelling!)
Full Name:_____________________________________ (NB check spelling!)
Date of Birth:__________________________ ID Number: _______________________
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:___________________
Gauteng Water Polo Association's Bank Account:
BANK: Standard Bank
Account Numer: 000199044
Branch Code: 000205 or 00020500
Your reference: Initials, Surname, Age and Gender
Example: RM Smith U19 G
(Note: Please add an additional R10 for cash deposits)
