TIP/Rep Nominations BNA Representative Nomination 2016First Name *Surname *Date of Birth *Address *Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryPrimary email contact *Primary phone contact *Parent's Name (if U18) Parent's Email (if U18) Parent's Phone (if U18) Club *ChooseBlue JaysFeverKedron LionsNorthside ChiefiesNorths St JosephsRidgettesSteelersWavellOtherPreferred Position #1 *ChooseGKGDWDCWAGAGSPreferred Position #2 *ChooseGKGDWDCWAGAGSAny other comments UNDERSTANDING YOUR MEDICAL HISTORY This MUST be completed by a parent/carer if nominee is under 18Emergency Contact Name *Relationship *Emergency Contact Number *Medical Practitioner *Medical Practitioner Phone *Medicare Number *Private Health Insurance Provider Does your child suffer from any of the following medical conditions AsthmaDiabetesAllergiesHepatitis B/CGlandular FeverTravel SicknessHeart DiseaseEpilepsyBlood Pressure AbnormalitiesRheumatic FeverJoint InjuriesSleepwalkingOther (please specify below)Other Medical Conditions List any medications prescribed by a medical practitioner IN CASE OF ACCIDENT...Do you give permission for BNA officials to seek appropriate medical help for your child? *YesNoIs your child permitted, if necessary, to receive a blood transfusion? *YesNoIs your child permitted, if required, to receive anaesthetic? *YesNoCan your child take ASPIRIN? *YesNoDo you consent to your child being provided PARACETAMOL as required? *YesNoDo you consent to your child being provided NUROFEN as required? *YesNoAre you/Is your child allergic to PENICILLIN? *YesNoAre you/Is your child immunised against TETANUS? *YesNoDECLARATIONS *By checking this box you give permission for the officials of Brisbane Netball Association to obtain medical attention for you/your child as required *By checking this box you give permission for photos or video of you or your child to be used by BNA for various internal and external publications including for use on the website and social media forums and/or for internal analysis By checking this box you give permission for your child to travel in a car/bus driven by a Brisbane Netball Association official as and when required *By checking this box you are committing to the programs in full and meeting all associated costs, if selected VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank: