Additional information

Date of Birth*

Residential Address*

Nominating for*

Preferred Cap Number*

Do you require bathers*

Women's Bather Size

Men's Bather Size

Quantity of Bathers

Do you require a Polo Shirt*

Women's Polo Shirt Size

Men's Polo Shirt Size

Quantity of Polo Shirts*

Do you require a Hat*

Quantity of Hats

Do you require transport to/from Perth to Busselton*

Yes

Do you require accommodation in Busselton*

Yes

Do you have any medical conditions*

Please enter any further information or comments for your Manager Max. 255 characters

I will be available for the 2025 State Country Water Polo Champs*

I agree to pay a $100 deposit & pay all other amounts owing by 31st Dec 2024*

I agree to attend additional training sessions*

I agree to attend & participate in all fundraising events*

Yes

I would prefer to pay my own way & not fundraise

2025 WA State Country Water Polo Championships