First Name required

Surname required

Date of Birth (DD/MM/YYYY) required

Gender required
Please Select Female Male

Address required

Suburb/Town required

Postcode required

Home Phone required

Athlete Mobile Phone required

Athlete Email required

First Name required

Surname required

Relationship (i.e. Mother) required

Work Phone required

Mobile Phone required

Email required

Allergies required

Doctor required

Doctor Phone required

Health Fund

Health Fund Number

Medicare Number required

Medication

Medical Operations

Club
Please Select Illawarra Nowra Velo Southern Highlands Other

Coach required

Practice Schedule for past 12 months required

Your results in Cycling (National, State, and Club) required

Results in Other sports, if not Cycling required

What do you believe you can offer the IAS Cycling Program? required

What do you believe the IAS Cycling Program can offer you? required

Write a brief summary of your goals and expectation both in Cycling and personal achievement

Athlete: I am applying for a position in the IAS 2012 Cycling Program. I certify that all information supplied herein and in any attachments is true and correct. If selected, I agree to fulfill all obligations to the IAS program. required
I agree and wish to nominate I do not agree

Parent/Guardian (if under 18): I give permission for my child to apply for an IAS Cycling Scholarship and attend any selection trials. required
I agree I do not agree

I have read and understand the "IAS Guide to Athlete Commitment" required
Yes No