Interstate Medical Personnel Application

Name*
First Last
Are you a Registered Teacher?*
- Yes
- No
School Name*
School Address*
Street Address Suburb Post Code
School Phone*
Teaching History - Please complete information for the past 5 years*
School Role Years at this school
Current Employer*
Do you have a Working With Children Check?*
- Yes
- No
Working With Children Check Expiry Date*

Do you have qualifications relevant to the position?
- Yes
- No
Qualification*
Briefly outline your skills and attributes relevant to the position*
Detail your involvement in sport at school or community level*
Supply any additional information to support your application
Referee 1*
Name Position Phone Email
School Principal Permission*
- I understand it is my responsibility to gain approval from my school principal to particiapate in the SSWA program as an Interstate Official
Upload Qualifications*
Accepted file types: jpeg, jpg, pdf, doc, docx.
Please upload evidence of your relevant qualifications.