Antrim Borough Council – Elite Athlete Support Scheme– Application Form
Elite Athlete Support
Scheme
Application Form
Please make sure you that you read the Guidance Notes attached before completing this form. If you have any particular communication needs, please let us know and we will try to meet them e.g. large print other language.
Should you have any queries or need help in completing this form please do not hesitate to contact: Sportand Physical Activity Development Manager on:
02894463113
Once completed forms should be returned to by
Monday 31March 2014,12noon to:
Sportand Physical Activity Development Manager
Antrim Borough Council
Antrim Civic Centre
50 Stiles way
Antrim
BT41 2UB
Please complete the form using typescript or printing clearly in ink
Elite Athlete SupportScheme:APPLICATION FORM
1.Personal Information
Name: ______
Address: ______
______
E-mail: ______AGE: ______
Telephone number: ______(Home) ______(Mob)
Name of Employer(if any): ______
Current School/University (if any): ______
2.Sporting Information
Sport: ______
Representing: County/ N.Ireland / Ulster / Ireland / Great Britain
Club represented: ______
Contact name (coach/manager etc): ______
Telephone number (Coach/Manager etc):______
Club Address and Training venue: ______
______
Governing Body of Sport: ______
Address: ______
______
Name of contact in Governing Body: ______
Telephone number: ______(Home) ______(Mob)
E-mail: ______
- Have you received support from any other source in the last three years?
Yes No (Please tick appropriate box)
If yes, please detail below
Year / Details / Amount / Date- Are you currently a member of a County, Inter Provincial, National or International Squad in your sport?
Yes No (Please tick appropriate box)
If yes, please detail below:
- Do you currently represent Northern Ireland/Ulster/ Ireland/Great Britain in any age category of your sport?
Yes No (Please tick appropriate box)
If yes, please detail below:
- Are you currently ranked within the top 10 (Senior Level) in Northern Ireland in your sport?
Yes No (Please tick appropriate box)
If yes, please detail below:
- Are you currently competing at International Level in your sport?
Yes No (Please tick appropriate box)
If yes, please detail below:
- Please state within the last six months:
- Any International Competitions (County or GAA) you have participated in.
Competition / Event / Venue / Date / Result
- Any occasions you have represented Northern Ireland / Ireland / Great Britain / Ulster.
Please give results, ranking or information as to how well you performed.
Country/Team Represented / Date / Result- Please state your future intentions (next 6 months) to compete at International Level or the next competitions you have been selected to represent County/Northern Ireland / Ireland / Great Britain / Ulster.
Country/Team Selected for / Competition / Event / Venue / Date
- Please give some details of any personal achievements in your chosen sport (include any press clippings, photographs, rankings, etc)
(Continue on a separate sheet if necessary)
- If you are a member of a Sports club within the Antrim Borough please demonstrate how you are an active member within that club.
- Please enclose written confirmation from your Governing Body.
This must confirm your answer to Question 4, 5, 6 or 7 in this application. Applications will not be considered unless accompanied by this confirmation.
13.Elite Athlete Support Scheme
Athletes applying for theElite Athlete Support Scheme may choose support from one of the following options: (please tick)
- 50% reduction in Antrim Forum fitness and Spa membership (min age 16)and 50% reduction on Antrim Forum facility costs (by arrangement)
- Support through Antrim Sports Advisory Association*
*Support through Antrim Sports Advisory Association is as follows:
- Enkalon Youth Sports Bursary which provides financial support to athletes under the age of 21 years*.
- Antrim Sports Advisory Association Grant Aid for Elite Athletes over the age of 21 on an individual and club basis*.
* Separate criteria apply
13. Declaration
- I certify that the information provided is true, accurate and complete.
- I understand the terms and conditions of the Elite Athlete Support Scheme.
- I hereby agree to abide by the rules and administrative arrangements as laid down by the Elite Athlete Support SchemeGuidance Notes.
- If successful in receiving an Elite Athlete Support, I hereby agree to participate free of charge in any promotional and marketing activities relating to Antrim Borough Council Leisure Facilities as requested.
SIGNATURE OF APPLICANT
NAME (PRINT):______
SIGNED: ______
DATE:______
If the applicant is under 18 years of age, this form must be countersigned by a parent or guardian
PARENT / GUARDIAN NAME (PRINT)______
SIGNED: ______
DATE:______
SIGNATURE ON BEHALF OF GOVERNING BODY
NAME (PRINT):______
SIGNED: ______
DATE:______
14. Checklist
Any additional information to support your application
Written confirmation from your Governing Body
A signed copy of the declaration
Does the application contain an original signature?
Have all relevant sections of the application form been completed?
Signed: Date:
Official Use Only
Panel considerations:
Date:
Permit agreed from: ______To: ______
1.______2.______3.______