Elite Athlete Scheme

It is important that you read the Guidance Notes attached before completing this form. If you have any further queries, please do not hesitate to contact the Sport & Wellbeing Development Unit; Sports Development, Causeway Coast and Glens Borough Council.

Section 1

Name

Address

Postcode

Home Phone

Mobile

Date of Birth

Name of Employer

Current School/University

Section 2

Sport

Are you a member of any of the following squads in your sport?

Ulster

Northern Ireland

Ireland

Great Britain

Age / Level

e.g., U-18, U-21, Senior and Veterans etc

Club Represented

Club Contact

coach/manager

Club Address

Club Postcode

Contact No.

Email Address

Name of National Governing Body

NGB Contact Name

NGB Address

NGB Postcode

NGB Contact No.

NGB Email Address

Section 3

Are you receiving assistance from another source?

Yes

If yes, please provide the following information:

Assistance Sources

Name of Organisation/funding body providing assistance	Nature of assistance e.g., amount of funding	Duration of assistance e.g., one off payment, 1 year agreement etc. (Please provide dates)

Section 4

Do you currently represent Ulster / N. Ireland / Ireland / Great Britain in any age category of your sport?

Yes

If yes, please detail

Are you currently ranked within top 10 (Senior Level) in N. Ireland in your sport?

Yes

If yes, please detail:

Are you currently competing at International Level in your sport?

Yes

If yes, please detail:

Please state within the last 12 months

Any international competitions you have participated in

Competition/Event	Venue	Date

• Any occasions you have represented Ulster / N. Ireland / Ireland / Great Britain

Country/Team Represented	Competition/Event	Date

Please state your future intentions (next 12 months) to compete at international level or next competition you have been selected to represent Ulster / N. Ireland / Ireland / Great Britain

Country/Team	Competition/Event	Venue	Date

Please upload written confirmation from your governing body that you belong to one of the previous mentioned elite programmes/squads

Section 5

Declaration:

I certify that the information provided is true, accurate and complete.
I understand the terms and conditions of the Elite Athlete Scheme.
I hereby agree to abide by the rules and administrative arrangements as laid down by the Elite Athlete Scheme Guidance Notes.
If successful in receiving Elite Athlete Scheme membership, I hereby agree to participate free of charge in any promotional and marketing activities relating to Council Leisure / Recreation Facilities as requested.

Signed

(To be signed by parent/guardian for applicant under the age of 18)

Signature