Page 1

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Personal Details (Not Applicable)

Applicant * Required

Title

First name

Last name

Applicant Primary Address * Required

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Address line 1

Address line 2

Suburb/Town

State/Province

Postcode

Country

Applicant Primary Phone Number * Required

Must be an Australian phone number.

Applicant Primary Email * Required

Must be an email address.

Date of Birth * Required

Must be a date.

Sport / Impairment (Not Applicable)

What is the eligible health condition of the athlete. Multiple options may be selected if required * Required

Response required.Response required.

Impaired Muscle Power (i.e. complete or incomplete spinal cord injury, spina bifida, muscular dystrophy)

Impaired Passive Range of Movement (i.e. arthrogryposis, joint contracture)

Limb Deficiency and/or Limb Length Difference (i.e. amputation, congenital limb deficiency, dysmelia)

Short Stature (i.e. achondroplasia, growth hormone dysfunction, osteogenesis imperfecta)

Coordination Impairments: Hypertonia, Motor Ataxia, Dyskinesia (i.e. cerebral palsy, traumatic brain injury, stroke, multiple sclerosis)

Vision Impairment (i.e. retinitis pigmentosa, rod cone dystrophy, diabetic retinopathy)

Intellectual Impairment (i.e. have restriction in intellectual functioning & adaptive behavior which effects conceptual, social and practical skills required for everyday life)

Other:

Clear the selected value for What is the eligible health condition of the athlete. Multiple options may be selected if required

Please describe your impairment in your own words (i.e. single below knee amputee) * Required

Must be no more than 150 characters.

Summer Para Sport (If Applicable)

Blind Football

Boccia

Goalball

Para Archery

Para Athletics

Para Badminton

Para Canoe

Para Climbing

Para Cycling

Para Equestrian

Para Judo

Para Powerlifting

Para Rowing

Para Swimming

Para Table Tennis

Para Taekwondo

Para Triathlon

Para Shooting

Sitting Volleyball

Wheelchair Basketball

Wheelchair Fencing

Wheelchair Tennis

Wheelchair Rugby

Clear the selected value for Summer Para Sport (If Applicable)

Winter Para Sport (If Applicable)

Para Alpine Skiing

Para Biathlon

Para Ice Hockey

Para Nordic Skiing

Para Snowboard

Wheelchair Curling

Clear the selected value for Winter Para Sport (If Applicable)

What is your current involvement in the sport related to the equipment request? * Required

Response required.

Compete in club activities or competition

Compete in regional or state competition

Compete in national competition

Compete in international competition

Recreational

Still rehabilitating following acquiring impairment

Not currently competing or participating in sport

Clear the selected value for What is your current involvement in the sport related to the equipment request?

If you are Classified for any sport, please list the details (i.e. Para athletics T46 & F46, Wheelchair Basketball 3.0)

Must be no more than 150 characters.

If you are Categorised by your sport and you know your current level of Categorisation, please provide * Required

Response required.

Representative

Emerging

Developing

Podium Potential

Podium Ready

Podium

I am catagorised, but don't know which level

I am not categorised

Clear the selected value for If you are Categorised by your sport and you know your current level of Categorisation, please provide

Round: Para Sport Equipment Enhancement Program - Stream 1 or 2 (Athletes) - December + January

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Personal Details (Not Applicable)

Sport / Impairment (Not Applicable)

Grant Information

Technical Assistance