List all illnesses and injuries that have affected the Athlete's training in the past 12 months and the name and address of any medical practitioner consulted in relation to the condition. Older injuries with ongoing effects are also to be declared.
I hereby authorise any hospital, physician or other person who has attended or examined me to provide to Basketball Queensland, or its representative, any and all information with respect to any illness or injury, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. A copy of this authorisation shall be considered as effective and valid as the original.
I wish to be considered for entry to the Basketball Queensland National Performance Program Scholarship Program, and I declare that all information submitted on this application form is correct and complete. I understand that Basketball Queensland reserves the right to vary or reverse any decision regarding admission made on the basis of incorrect or incomplete information.
For applicants under 18 years of age, the parent, guardian or custodian who is the first legal point of contact must sign.
Please note that you may be required to submit the following documents to Warwick Cann NPP Director/Head Coach & General Manager- Game Development if requested:
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