Larne Borough Council

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: ______

1. Have you received support from any other source in the last three years?

Yes No (Please tick appropriate box)

If yes, please detail below

1. 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:

1. 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:

1. 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:

1. Are you currently competing at International Level in your sport?

Yes No (Please tick appropriate box)

If yes, please detail below:

1. Please state within the last six months:

1. Any International Competitions (County or GAA) you have participated in.

1. Any occasions you have represented Northern Ireland / Ireland / Great Britain / Ulster.

Please give results, ranking or information as to how well you performed.

1. 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.

1. 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)

1. If you are a member of a Sports club within the Antrim Borough please demonstrate how you are an active member within that club.

1. 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.______