NOMINATION FORMDUE DATE: 10Th February 2018
INTERNATIONAL TETRATHLON - USA | 13thJuly – 30thJuly 2018[1]
NOMINATION FORMDUE DATE: 10th February 2018
The following information must be your legal name as represented on your passport. The information you provide will be used to purchase airline tickets, insurance and any travel bookings.
Competitor’s Details
State Association: ...... Competitor’s Club: ......
Full Name:......
Postal address:...... Postcode: ......
Residential address: ………………………………………………………………………………………………………………………………………………………
Date of Birth: ……………………………………… Age at 1st Jan 2018: (between 16 and 21) ......
PH(H): ...... PH(M):......
Email: ......
Travel Details
Closest domestic airport: ......
Team member will need to have a valid Passport with an expiry date ofFebruary 2019 or later
Parent’s/Guardian’s Details (Emergency Contacts)
Parent/Guardian: ...... Relationship: ......
PH(H): ...... PH(M):......
Email: ......
Parent/Guardian: ...... Relationship: ......
PH(H): ...... PH(M):......
Email: ......
Cost of tour: $5500 (estimate)
Bank details for EFT payment of the tour costs will be sent to you when the team is confirmed. Cheques not accepted.
Please identify who will be paying the invoice (delete which one does not apply) – Competitor or State Office
ENDORSEMENT OF STATE ASSOCIATION(State can nominate one male and one female)
We have pleasure in nominating ...... to represent our State and Australia.
President: ...... Date: ......
CEO/State Coach: ...... Date:
INTERNATIONAL TETRATHLON North and South Carolina, USA | 13thJuly – 30thJuly 2018
COMPETITORPROFILEDUE DATE: 10th February 2018
Please attach a jpeg passport style photo, head and shoulders.
Full name: ......
Sport
Coach name: ...... Favourite discipline:......
When did you start riding? ...... When did you join Pony Club?......
Why have you chosen to apply?......
…..…………………………………………………………………………………………………………………………………………………………………………………
Which National and International events have you participated in? (year/event/name):......
General
Ambitions: ......
Awards/Honours:......
Efficiency Certificates achieved: A B K C* C D D* E (should have at least C certificate)
Other Pony Club achievements: ......
School/ academic achievements: ......
......
......
Hero/Idol: ......
Other Hobbies:......
Please include anything else that you would like the Selection Panel to know
Competition Results Refer to the PCA National Tetrathlon Rules and document results against those standards.Provide at least 2 results for each phase if possible. Attach another page if necessary
State, National and International Results
Year / Event / Tetrathlon phase / ResultReturn this form to:
| P: 03 95965390
Acknowledging the financial support of the Australian Sports commission
[1]Actual departure and arrival times in Australia may vary, depending on flight schedules and international time zones