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2014 Exercise Science (Full) Membership Application Form – NUCAP For graduates of a NUCAP (National University Course Accreditation Program) accredited exercise science course within the last 2 years. For a

full list of NUCAP accredited courses please refer to www.essa.org.au/foruniversities/accredited NUCAP courses. If you have not completed a

NUCAP accredited exercise science course please complete the 2014 Exercise Science (Full) Membership Application Form – NON NUCAP

Please use the following table as your checklist. ESSA will not assess incomplete applications.

Application

page reference

Tick when

completed

BEFORE SUBMITTING THIS APPLICATION FORM PLEASE READ AND COMPLETE THE FOLLOWING POINTS

1. Complete personal details (Section A). Page 2

2. Complete payment details (Section B).

Include membership payment of $270.00 including GST or $185.00 including GST if you were a student member of ESSA in

2013.

Please complete the credit card payment details or enclose a cheque or money order made payable to Exercise & Sports

Science Australia. If paying by credit card please ensure your credit card is current.

Please note, credit card payments attract a merchant fee of 1.5% of the quoted fees.

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3. Complete personal declarations (Section C). Page 4

4. List a professional referee (Section D). Page 4

5. List university qualifications achieved (Section E). Page 5

6. Provide official and final academic transcript/s.

Copies must be signed and authenticated by a Justice of the Peace or notary.

Provide a letter of university course completion if required.

ATTACH TO

APPLICATION

7. Complete the statutory declaration (Section F). Page 6

8. Attach work experience/practicum logbook (140 hours) with completed practicum reference form/s (Section G & H).

Pages 7-8

ATTACH TO

APPLICATION

9. Attach any additional documentation e.g. marriage certificate as proof of name change from that appearing on

university qualifications.

ATTACH TO

APPLICATION

This application form is relevant for all applicants applying for exercise science membership in 2014. Please read the 2014 Exercise Science membership NUCAP application guide prior to completing this form. Please allow 30 working days for assessment of this application and an additional 30 working days should submission of further information be required.

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SECTION A – Personal details

Title Given names Surname DOB Email *This is required for your website login Are you of Aboriginal or Torres Strait Islander origin? Yes No

Postal address Address

Town/Suburb State Postcode

Phone Fax

Work address

Address

Town/Suburb State Postcode

Phone Fax

Mobile

Current employment

Previous position/title

Please indicate your primary, and if applicable your secondary, work sector by placing a 1 (for primary area of employment) and 2 (for

secondary area of employment if applicable) in the boxes provided:

Federal government organisation Research/education institution Sporting club/institution

State government organisation Fitness club/institution Health care organisation

Hospital Mining Private company

Sporting club/institution Workers compensation agency Student

Not currently working On leave

Please indicate your primary, and if applicable your secondary, area of employment by placing a 1 (for primary area of employment) and 2 (for secondary area of employment if applicable) in the boxes provided:

12 Greenway Drive

Hamilton QLD 4228

0422 598 333

Brisbane QLD 422

3824 5569

Smiths Gymnasium

Trainer

Coach at my local baseball club

Graduate101@hotmail.com 27/05/1986

Graduate John Recent Mr

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Administration/project officer Aged care Chronic disease management

Chronic disease prevention Clinical assessments & screening Coaching & athlete development

Community health/health promotion Education Fitness industry

Hospital Management Occupational health & assessment

Rehabilitation case management Rehabilitation service provider Sports science testing

Strength & conditioning Workplace health or corporate health

Privacy statement: Exercise & Sports Science Australia acknowledges and respects the privacy of its members. All information provided on this form is subject to ESSA’s Privacy Policy. Details of this policy can be viewed on ESSA’s website www.essa.org.au. ESSA uses and discloses personal information only for our primary functions or a directly related purpose e.g. release of information to organisations including Medicare, Department of Veterans’ Affairs, private health funds, Workcover, National Health Services Directory and relevant condition organisations e.g. Arthritis Australia release of information via the Find an AEP search function on ESSA’s website. If you do not wish for your information to be disclosed please indicate here with a tick . You have the right of access to and alteration of your personal information in accordance with the Privacy Act. Please direct any enquiries you have in relation to this matter to ESSA’s Executive Officer on ph. +61 7 3862 4122.

SECTION B - Payment details

Cheque or money order for $270.00 made payable to Exercise & Sports Science Australia is attached

(or $185.00 if a student member of ESSA in 2013)

OR

Card type (Please select) VISA Mastercard

Cardholder’s name _________________________________________________________________ Expiry of card ____ / ____ month/year)

Card number

I authorise Exercise & Sports Science Australia to debit my credit card for the amount of $270.00 plus a 1.5% merchant fee. (or $185.00 plus a 1.5% merchant fee if a student member of ESSA in 2013)

Yes No

By submitting this application I acknowledge that Exercise & Sports Science Australia will debit my credit card for the amount of $55.00 plus a

1.5% merchant fee (non-refundable) should the application be declined or if the request for further information is outstanding for more than 1

month.

Signature Date

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SECTION C - Personal declarations

Declarations

a) I certify that the information supplied on and with this form is true and correct.

Applicant’s signature Date

b) If accepted as an exercise science member of the association I agree to abide by the ESSA Code of Professional Conduct and Ethical

Practice.

Applicant’s signature Date

c) I certify that if I am working with clients/human subjects (no matter the type) I will have current professional indemnity and public

insurance and hold current first aid and cardiopulmonary resuscitation (CPR) qualifications.

Applicant’s signature Date

SECTION D – Professional referee

Please provide the name and contact details of a professional referee

Title Name

Postal address

Phone Email

Qualification

Current position/title

Current employer

Capacity in which applicant is known to the referee

Please note that ESSA may contact your professional referee to verify information contained within the application

J. Graduate 12 December 2013

J. Graduate

12 December 2013

J. Graduate

12 December 2013

Ms M. Smith

GPO Box 12 Brisbane

1234 5678 msmith@frogpond.com

Bachelor of Exercise Science

Director/ Owner at Smith Gymnasium

6 years

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SECTION E - University qualifications achieved

Please complete the following information, listing university qualifications

Degree Code

University Year

completed

Bachelor of Exercise & Movement Science XN53 University of Australia 2013

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Page 7

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SECTION F - Statutory declaration

Commonwealth of Australia

STATUTORY DECLARATION

Statutory Declarations Act 1959

1 Insert the name, address

and occupation of person

making the declaration

I,1 John Recent Graduate (name) , of

12 Greenway Drive, Hamilton, QLD (address)

And of Personal Trainer (occupation)

make the following declaration under the Statutory Declarations Act 1959:

2 Set out matter declared to

in numbered paragraphs

2

“The attached documentation accurately indicates how the criteria for necessary and sufficient knowledge,

skills and competencies are met in order to fulfil application requirements for exercise science (full)

membership with Exercise & Sports Science Australia”.

I understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an

offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in this

declaration are true in every particular.

3 Signature of person

making the declaration 3 John R Graduate

4 Place

5 Day

6 Month and year

Declared at 4 University of Brisbane on

5 7th of

6 May 2013

Before me,

7 Signature of person before

whom the declaration is

made

7 Jane Green

8 Full name, qualification

and address of person

before whom the

declaration is made (in

printed letters)

8

(name) Jane Green

(qualification) PhD - Full time Tertiary Educator

of (address) 1 University Drive, Brisbane, QLD 4000

Note 1 A person who intentionally makes a false statement in a statutory declaration is guilty of an offence,

the punishment for which is imprisonment for a term of 4 years — see section 11 of the Statutory Declarations

Act 1959.

Note 2 Chapter 2 of the Criminal Code applies to all offences against the Statutory Declarations Act 1959 —

see section 5A of the Statutory Declarations Act 1959.

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Reference for: Dear Colleague The above applicant has applied for membership with Exercise & Sports Science Australia (ESSA) as an exercise scientist. Requirements of this membership include a minimum of 140 hours practicum. Please complete the following form based on your experience with the above applicant: Skills and experience In the following table, please provide evidence of the practicum the applicant has gained in the relevant area of exercise science: (expand boxes where necessary)

Total hours and

dates* Description of Activities

Site/location

Co

mp

ete

nt

No

t

Co

mp

ete

nt

No

t ab

le t

o

com

me

nt

Name and signature of

referee

6/1/12 - 5/5/13

32 hours

Delivering outdoor group exercise

programs

Smiths Gymnasium √

M.Smith

M Smith

6/1/12 - 5/5/13

19 hours

Delivering group cycling classes Smiths Gymnasium √

M.Smith

M Smith

6/1/12 - 5/5/13

12 hours

Preparation - planning the group

outdoor and cycling sessions

Smiths Gymnasium √

M.Smith

M Smith

6/1/12 - 5/5/13

7 hours

Delivering one on one exercise sessions Smiths Gymnasium √

M.Smith

M Smith

Total

70 hours

*Clinical supervisor: student ratios may be up to 1:5, with the proviso that there must be some 1:1 contact for each placement. Declaration: (To be completed by the supervisor) I certify that the information supplied is true and correct

Signature Date

Title Name

Background in exercise physiology (brief summary only): I’m an AEP

Phone Fax

Email

Please attach this form to practicum logbook

SECTION G - Practicum reference form

John R Graduate

M. Smith Mrs

Bachelor of Exercise Science ( Oxford, 2005), 7 years full time work experience running own fitness business with healthy clients and moderate risk

clients.

12345679 12345678

msmith@frogpond.com

M Smith

5/5/14

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SECTION H - Exercise Science Practicum/Work Experience Logbook (Apparently Healthy)

Date Number of

Hours Case Description Description of Services Supervisor

Supervisor’s Signature

Applicant’s Signature

6/1/12 1 hour

30 mins

15 mins

TOTAL: 1 hour 45

6 adults (2 male, 4 female) aged between 22-31 years. All apparently healthy with goals to increase fitness levels.

Conducted an outdoor group fitness session. Instructed a cardio warm –up of jogging and stretching for 10 mins. Demonstrated circuit aerobic activities (such as step-ups, ladder runs & burpees) and resistance exercise using body weight, medicine balls and dumbbells (such as chest press, tricep dips & push-ups). Motivated clients during the circuit class as well as illustrated appropriate techniques. Varied the levels of exercises to suit differing fitness levels such as level 1, 2 & 3 push-up modes (45 mins). Instructed the cool-down with stretches (5 mins).

Design exercise session. Plan exercise stations, including both aerobic & resistance exercises. Ensure that exercises chosen can be modified for varying fitness levels.

Find a large grassed area with some shade in park. Set-up each circuit station with weights, mats, balls etc ready for outdoor exercise session.

M.Smith M Smith Tim Shore

3/4/12 TOTAL = 1

hour

Group stationary cycling class. 12 20-35 y.o. males and females. All completed PARQ - no health conditions

Led the set format class, spoke to new comers before the session told them to only do half the increases of the rest of the group, stay under 14 on RPE scale, let me or assistant instructor know if they weren’t feeling well. Described challenges for more experienced class members. Gave verbal feedback regarding bike technique to class members.

M.Smith M Smith Tim Shore

5/5/13 TOTAL = 1

hour

64 y.o. female, taking medication for high cholesterol (4 years), cleared by AEP to be treated as apparently healthy

Took client through the program pre-written by supervisor (AEP). Incremental warm-up on treadmill, 20 min aerobic walking varying hill incline throughout. Monitored RPE, facial expressions and colour. Resistance program: wall push-ups, fitball squat, theraband hip abduction/adduction, balance activities, dumbbell bicep curls, tricep pushdown, abdominal bracing and flexibility.

M.Smith M Smith Tim Shore

SECTION H - Exercise Science Practicum/Work Experience Logbook (Sports Science/Sports Performance)

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Date Number of

Hours Case Description Description of Services Supervisor

Supervisor’s Signature

Applicant’s Signature

15/5/13 to

25/6/13

Testing = 8 hours

Program design = 1 hour

Program 2 x 1 hour per week (4 weeks) = 8 hours TOTAL: 17 hours

Group of 24 women aged between 17 and 21 years old. Strength & conditioning training program for sports team.

Strength and conditioning training for QLD women’s state development program (U21’s) hockey team. My role initially involved assessing and recording fitness data for the team (pre-season). These tests included: weight (digital scales), height (stadiometer), BMI, body composition (skinfolds), muscular strength (3RM chest, legs, arms, abdominals) and aerobic fitness (VO2max). All data was recorded and entered into the computer. This information was then used to design and implement conditioning programs to maximise the strength, power and endurance performance of the team. It also aims at preventing injury. I was involved in developing the exercise program with the head coaches & health professionals as well as assist with the implementation and delivery. At the gym my duties were to assist with exercise technique, ensure safe use of machines, and collect RPE data. The strength and conditioning sessions mainly involved aerobic, resistance and flexibility exercises being progressively overloaded from the previous session. The modes of exercise altered to maintain interest & incorporate cross training. Plyometric and power exercises (anaerobic) were sometimes added into the exercise programs. Please refer to the two attached example programs for a more detailed description.

L. Citizen L Citizen Tim Shore

20/5/13 TOTAL

18 x 18-28 y.o. males, senior football players, no health conditions

All players were fitted with a shoulder harness with the GPS monitor fitted between the shoulder blades to obtain match data. (30 mins) Following the match, data from all units were downloaded into the GPSports analysis software to prepare individual player reports including: total distance, total match time, maximum speed, average speed, acceleration and time spent in 5 different speed zones (1 hr). This data was then given to the head strength and conditioning coach who uses this information to help determine training loads that are

L. Citizen L Citizen Tim Shore

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1.5 hours appropriate for different playing positions.

SECTION H - Exercise Science Practicum/Work Experience Logbook (Exercise and Sports Science Research)

Date Number of

Hours Case Description Description of Services Supervisor

Supervisor’s Signature

Applicant’s Signature

8/4/13 and

9/4/13

6 hours per day (approx 3 hours per subject)

TOTAL: 12 hours

Four amateur male golfers aged 22, 25, 23 and 27. Data collection for a research study into back muscle activation during golf swing.

I was a research assistant for an investigation into truck activation during golf swing. My role was to collect and record data for four subjects. These included taking height and body mass. It also included setting up each subject with surface EMG on their erector spinae, external obliques, rectus abominus and latissumus dorsi. This involved shaving and cleaning the skins surface with alcohol and placing the pairs of bipolar surface electrodes on both sides of the body. Reference electrodes were also positioned over spinous processes. Each subject was then instructed to perform a total of 15 golf swings with a driver. This was conducted every 2.5 minutes to eliminate fatigue. During this time, my roles were to continuously monitor positioning and contact of electrodes on the truck as well as monitor quality signal from the EMG. I also had to upload the collected EMG data onto the study laptop into the appropriate folder as well as check the figures to ensure that a retrial did not have to be undertaken. When all the swing trials were completed, I removed the electrodes from the subject & disposed of them.

S. Brown S Brown Tim Shore

1/11/13 and

8/11/13

2.5 hours per day

An elite male triathlete aged 27 years old. No current injuries.

I assisted an accredited exercise physiologist conduct two separate V02 max tests with blood lactate on an elite triathlete in our university laboratory. These were conducted one week apart. The testing was conducted to determine training zones/ranges.

Pre-test assessments: My role was to assist with the set-up and conduction of the V02 max test, as well as take weight, height and body composition measurements before the first test. The BodPod was used to

S. Brown S Brown Tim Shore

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TOTAL = 5 hours

measure body composition. I calibrated the machine and ensured the subject was dressed appropriately (cap & nose plug), then sat with the AEP at the computer whilst the testing was undertaken (5 minutes).

V02 max test: For both tests (cycle and treadmill) we used the CosMed K4B2, which is a portable and mobile V02 testing unit. I was responsible for calibrating the device, setting up the machine to collect heart rate and gas exchange, placing the device on the subjects back and ensuring the face mask had a good seal around the nose and mouth. Once the test had commenced, it was my duty to progressively increase the speed of the treadmill (2km/hr every 2 mins) or load on the bicycle (50 W every 3 mins). I also took blood lactate measurements every 30 seconds before the end of each stage (using lactate pro machine). At completion of the V02max test, I removed all equipment attached to the subject. Results: Height (cm):176cm Weight (kg): 65kg (cycle) 64.5kg (treadmill) Body composition (% fat): 8% Duration of V02 max test: 15 mins (cycle), 14 mins (treadmill) HR max (bpm): 193 (cycle), 195 (treadmill) VO2 (ml/min/kg): 49.78 (cycle), 50.09 (treadmill) VC02 (ml/min): 3878 (cycle), 3700 (treadmill)

SECTION H - Exercise Science Practicum/Work Experience Logbook (Workplace Health)

Date Number of

Hours Case Description Description of Services Supervisor

Supervisor’s Signature

Applicant’s Signature

4/6/12 TOTAL = 5 hours

Workplace fitness assessment for 5 workers (approx one hour per client with discussion). Client 1: 32 y.o. female, healthy

Took office workers through fitness tests set up in their boardroom. The testing involved the following measurements:

height

weight

waist and hip girth measurements

sit and reach flexibility

M.Smith M Smith Tim Shore

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Client 2: 56 y.o. male on medication for hypercholesterolemia for 2 years Client 3: 26 y.o. male, nil health issues Client 4: 47 y.o. female. Osteopenic Client 5: 39 y.o. female, healthy and very active.

shoulder flexibility

7 level abdominal test

5 min Harvard Step test After each testing session, BMI, waist to hip ratio and step test result were calculated. The client was taken through their results and compared to the available norm values. From these results, recommendations were made regarding an exercise program. Client 1 - had reduced shoulder flexibility and was shown some upper body flexibility exercises Client 2 - performed well on all tests and gave advice about cross training to vary from his usual daily walk Client 3 - scored very high on step test but poorly on flexibility and abdominal tests. Provided hamstring, lower back and upper body stretches as well as bracing activities to work on abdominal strength Client 4 - body weight resistance exercises were shown to help maintain bone density Client 5 - she is training for her first half marathon so a six month training plan was devised for this client.

SECTION H - Exercise Science Practicum/Work Experience Logbook (Hospital/Clinical Services)

Date Number of

Hours Case Description Description of Services Supervisor

Supervisor’s Signature

Applicant’s Signature

12/7/12 to

9/12/12

12 x 1 hours

sessions

Males and females aged 35-92. Cardiac investigation stress test (have completed unit EX315 covering BP and ECG analysis)

Prepared client measuring resting blood pressure and set up 12 lead ECG leads, gave instructions about the format of the test and how to walk on the treadmill if they weren’t familiar. The Bruce protocol was used in these testing session and was performed with a Cardiologist present. My role during the test was to control the treadmill. The cardiologist would discuss any abnormal ECG rhythms with me afterwards and expect me to explain what I thought the arrhythmias were and how they may affect exercise and was it appropriate if they were to participate in exercise.

M.Smith M Smith Tim Shore