Name *

First Name

Last Name

Date of Birth *

(Must be aged at least 13 years on at least one day during the scholarship period)

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile

(###)

###

####

Gender

Male

Female

Other

Does the applicant identify as being of Aboriginal or Torres Straight Island descent?

Yes

No

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Phone

(###)

###

####

Name of contact person at SSA

First Name

Last Name

Phone of contact person at SSA

(###)

###

####

Name of Coach

First Name

Last Name

Name of person completing this application

If not completed by the applicant (i.e parent / guardian)

First Name

Last Name

I confirm that the High Performance Manager or approved representative of my SSA and/or the RSA endorse and support this application *

Yes

I certify that the information provided in this application is true and correct

YES