AUSTRALIAN CANOEING INCORPORATED
2011 AUSTRALIAN CANOE POLO TEAM NOMINATION
2011Oceania ChampionshipsNominations close April23rd 2011
Nominee’s NameContact Address
Home Telephone
Email Address
Date of Birth / Club
AC Membership #
Oceania Championships
(please Circle) / Men / Under 21 Men / Under 18 Men
Women / Under 21 women / Under 18 Women
Veterans (Over 35) / Masters (Over 45)
Nomination Fee for all categories is a one off fee of $70 inc GST
Post Nomination form with cheque or online payment receipt to:
AC Polo Selections Manager
1 Torrens Avenue,
Felixstow SA 5070
ATHLETE ACKNOWLEDGEMENT
WARNING: THIS IS A LEGAL DOCUMENT THAT AFFECTS YOUR RIGHTS.
I, HEREBY ACKNOWLEDGE that:
1. I have read and understood the Team Members By Law and acknowledge the terms and obligations contained in the By Law, which are imposed upon me as a result of my selection to a Squad and subsequent signing of this acknowledgement.
2. I have been provided with a copy of the Australian Canoeing Selection Procedures Bylaw andthe Australian Team Selection Criteria Supplement for the Australian Team to compete in theevents. I agree to abide by the terms and conditions of these Selection Policies.
3. There will be some personal expense involved in attending the Selection Events, camps, eventsand tours as outlined in the Selection documents and I accept full responsibility for myexpenses. I understand that I will not be eligible to travel with the team nor compete in eventsif I have any monies outstanding on the date of departure of the team.
4. I understand that on selection to a Squad or Team, I am required to pay $70 (inc GST) as aSquad Administration Fee.
5. I understand that the information that I have provided herein will be included in an AustralianCanoeing database and may be disclosed on occasions to the Australian Sports Commission,including the Australian Institute of Sport, State Institutes and Academies of Sport, the International Canoe Federation, Event Organizers and the Australian Sports Drug Agency orotherwise in accordance with the Australian Canoeing Privacy Bylaw. I also understand thatinformation of a biographical nature including my name, date of birth, home state, results,career highlights and interests may be released to the media in response to general requests.
6. I am subject to drug testing by the Australian Sports Drug Agency and/or ICF, and will complywith both Australian Canoeing and International Canoe Federations Anti-Doping By-Lawand the relevant Australian Olympic Committee and Australian Sports Commissions Anti-DopingPolicies;
7. I will provide timely and accurate contact and training information to AC for the purposes ofdrug testing; and
8. I will maintain a designated level of fitness as determined by Australian Canoeing, and astandard of competitiveness prior to the relevant event for which I have been selected.
Declaration: I have read the above and the Bylaws and Selection Policy relating to my conduct as a member of the team and accept this nomination.
Athlete’s Signature
Parent or Legal Guardian
(if under 18) / Full name:
Signature:
Witnessed By / Full Name:
Signature:
Team Nominations must be accompanied by payment of $70 (includes GST)
Payment can be either online or by cheque or money order made out to Australian Canoe Polo Inc. Canoe Polo.
Forms should be posted with cheque/money order or online transfer receipt to:
AC Polo Selections Manager
1 Torrens Avenue
Felixstow SA 5070 / Online Banking Details:
BSB: 06 21 72
Acc #:1030 6814
Acc Name: Australian Canoe Polo Inc. Canoe Polo / Office Use Only
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