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					           WESTERN AREA SECONDARY SWIMMING

                                       SWIMMING NOMINATION

Name: ....................................................        Age: 12 / 13 / 14 / 15 / 16 / 17

School: ..................................................        Distance: 800m FS / 400m FS / 400m IM

                                                                  Female    /   Male



PERFORMANCES ATTAINED DURING 2011/2012

Information required:

     Event          Distance              Time             Event Conducted By            Venue         Date

1

2

3

This information is verified by:

Official’s Name: ..................................................
                                                                                }
                                                                                }
Position:            ....................................................       }
                                                                                }
                                                                                }      SWIMMING CLUB
Club:                ....................................................       }      INFORMATION
                                                                                }
Signature:           ....................................................       }
                                                                                }
                                                                                }
Date:                ....................................................



Sportsperson: ....................................................              }
                                                                                }
Principal:           ....................................................       }      SCHOOL INFORMATION
                                                                                }
Date:                ....................................................       }




This form must be submitted prior to the Regional Carnival. Please forward to the
Western Swimming convener Ingrid Corcoran (ingrid.corcoran@det.nsw.edu.au)
by Wednesday 22nd February 2012.

				
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