Scholarship Policy Application Form

ACTIVE SPORTS SCHOLARSHIP APPLICATION FORM

Personal Details

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Name ...........................................................................................................

Address ...........................................................................................................

...........................................................................................................

Post Code ....................................

Telephone Number Work .............................. Home .....................................

Existing coaching qualification(s) ...................................................................................

Do you have a disability? Yes/No

If yes please give details:

..................................................................................................................................

Ethnic Origin Bangladeshi o Pakistani o Black Caribbean o

Black African o Black Other o Chinese o

Indian o White o

Course Details

Course Title ...................................................................................

Course Start Date ......................... Course finish date ............................

Course Organiser ......................... Tel. No. ................................................

Course Venue ..................................................................................................

Course Cost ................................

Scholarship amount applied for £ ________ Percentage of course cost ______%

Your Coaching Experience

What is your current sports coaching experience?

...................................................................................................................................

What is the age of the young people you currently work with?

...................................................................................................................................

What sports club are you principally involved with?

..................................................................................................................................

Club secretaries name .............................. Tel No. ...........................................

(club secretaries may be contacted)

Signed ................................. Date .....................................

Noel Haines, Senior Active Sports Officer

Leicestershire, Leicester and Rutland, Active Sports Partnership, C/o Saffron Lane Sports Stadium, Saffron Lane, Leicester, LE2 7NQ