Applications Deadline is 1st June 2010

ADVANCED APPRENTICESHIP IN SPORTING EXCELLENCE

WATER POLO ELIGIBILITY FORM 2010

PERSONAL INFORMATION
FIRST NAME (S)
LAST NAME
GENDER
DOB
MAIN HOME ADDRESS
TERM AND BOARDING ADDRESS
REGION / NORTH WEST
NORTH EAST
EAST MIDLANDS
WEST MIDLANDS
EAST
LONDON
SOUTH EAST
SOUTH WEST
MAIN HOME TELEPHONE NUMBER
ATHLETE MOBILE NUMBER
MAIN E-MAIL ADDRESS
NATIONAL INSURANCE NUMBER
HAVE YOU BEEN RESIDENT IN THE UK OR EU FOR THE PREVIOUS 3 YEARS?
SPORT PERFORMANCE INFORMATION
SPORT
MAIN EVENT/POSITION
PERSONAL BEST/MAIN ACHIEVEMENT
TRAINING CLUB NAME
TRAINING VENUE
(PLEASE LIST FULL ADDRESS)
COACH NAME
COACH E-MAIL
SPORT SPECIFIC ASSESSMENT AGAINST AASE SELECTION POLICY
CRITERIA / YES / NO
ARE YOU WILLING TO COMMIT TO 15HRS PER WEEK OF WATER POLO TRAINING?
ARE YOU A CURRENT ENGLAND TALENT/GB YOUTH SQUAD MEMBER?
ARE YOU BASED AT A HIGH PERFORMANCE CENTRE?
(If yes please list whether this is Manchester or Crystal Palace)
IF YOU ARE NOT BASED AT A HIGH PERFORMANCE CENTRE, ARE YOU WILLING TO MAKE VISITS TO A CENTRE TO UNDERTAKE AASE WORK AND MEET WITH THE TALENT DEVELOPMENT OFFICER?
WHAT IS YOUR ULTIMATE AMBITION FOR WATER POLO?
HOW MANY HOURS PER WEEK DO YOU TRAIN?(AQAUTIC AND LAND TRAINING)
ACADEMIC INFORMATION
ARE YOU COMMITTED TO THE LISTED REQUIREMENTS? / COMPLETION OF 780 HOURS OF LEARNING
(either at school or via vocational sport related courses) / YES / NO
COMPLETION OF LEVEL 2 KEY SKILLS OR A GCSE RESIT, IF YOU ACHIEVE BELOW GRADE C IN MATHS AND/OR ENGLISH / YES / NO
LIST YOUR PREDICTED/ACTUAL GCSE GRADES
You MUST send us your “Statement of Results” as soon as you receive these.
If you attain below Grade C in Maths and or English you MUST either retake your GCSE exam or complete Level 2 Key Skills. / SUBJECT / PREDICTED GRADE / ACTUAL
GRADE
MATHS
ENGLISH LANGUANGE
ENGLISH LITERATURE
DO YOU PLAN TO GO TO SCHOOL/COLLEGE FOR SEPTEMBER 2010? / YES / NO
IF NO, ARE YOU COMMITTED TO WORK TOWARDS VOCATIONAL SPORT RELATED COURSES? / YES / NO
IF YES, PLEASE LIST WHICH COURSES YOU PLAN TO UNDERTAKE.
IMPORTANT NOTES
1.  You need to collate a total of 780 Guided Learning Hours in order to complete the AASE Programme.
2.  Each AS and A2 Level is worth 180 Guided Learning Hours
3.  Only BTEC courses in Sport contribute towards successful completion of the AASE Programme.
4.  Non sport related BTEC courses are not acceptable (Uniformed Public Services, Art and Design, Business e.t.c)
WHICH SCHOOL/COLLEGE WILL YOU BE ATTENDING AS OF SEPTEMBER 2009?
You MUST complete all fields so that we can send your school/college letters. / CONTACT PERSON
ADRESS LINE 1
ADDRESS LINE 2
ADDRESS LINE 3
POST CODE
WHICH SCHOOL ARE YOU COMPLETING YOUR GCSE’S WITH? (school name and address)
ADDITIONAL SUPPORT INFORMATION
DO YOU HAVE A LEARNING DIFFICULTY?
(INC DYSLEXIA)
IF YES, WHAT TYPE OF LEARNING DIFFICULTY DO YOU HAVE?
You MUST provide documentation to evidence this.
DO YOU CURRENTLY RECEIVE ANY SUPPORT AT
YOUR SCHOOL?
IF YES, WHAT TYPE OF SUPPORT DO YOU RECEIVE?
You MUST provide documentation to evidence this.
WILL YOU BE RECEIVING ANY TYPE OF SUPPORT AT YOUR SCHOOL/COLLEGE AS OF SEPETEMBER 2010?
IF YES, WHAT TYPE OF SUPPORT WILL YOU RECEIVE?
You MUST provide documentation to evidence this.
WHO CAN WE CONTACT TO DISCUSS YOUR SUPPORT REQUIREMENTS?
(Personal Tutor, SENCO, e.t.c) / NAME:
TITLE:
CONTACT NUMBER:
E-MAIL ADDRESS:
ANY OTHER COMMENTS (Fell free to attach any required documentation to the eligibility form)
EQUAL OPPORTUNITIES INFORMATION
(Please circle the most appropriate option)
Ethnicity (L12) / Code / Learning Difficulties/disabilities/health problems (L14) / code
Asian or Asian British-Bangladeshi / 11 / I consider myself to have a learning difficulty, disability or health problem / 1
Asian or Asian British-Indian / 12 / I do not consider myself to have a learning difficulty, disability or health problem / 2
Asian or Asian British-Pakistani / 13 / Disability (L15) / code
Asian or Asian British-Any other Asian Background / 14 / Visual Impairment / 01
Black or Black British-African / 15 / Hearing Impairment / 02
Black or Black British-Caribbean / 16 / Disability affecting mobility / 03
Black or Black-any other background / 17 / Other physical disability / 04
Chinese / 18 / Other medical condition
(epilepsy, asthma, diabetes) / 05
Mixed - White and Asian / 19 / Emotional/behavioural difficulties / 06
Mixed-White and Black African / 20 / Mental health difficulty / 07
Mixed-White and Black Caribbean / 21 / Temporary disability after illness
(post viral, accident injuries) / 08
Mixed-any other Mixed background / 22 / Profound Complex disabilities / 09
White-British / 23 / Aspergers Syndrome / 10
White-Irish / 24 / Multiple Disabilities / 90
White-any other White background / 25 / Other / 97
Any other / 98 / No disability / 98
Not known/not provided / 99 / Not known/information not provided / 99
Learning Difficulty (L16)
Moderate Learning Difficulty / 01 / Dyscalculalia / 11 / Other / 97
Severe Learning Difficulty / 02 / Other specific learning difficulty / 19 / No learning difficulty / 98
Dyslexia / 10 / Autism spectrum disorder / 20
DATA PROTECTION
1.  ASA/British Swimming/Institute of Swimming (IoS)
The ASA/British Swimming will use my personal data for the purpose of the IoS Apprenticeship scheme and I understand that by submitting this form, I am consenting to receiving information relating to the IoS Apprenticeship schemes by post, e-mail, SMS/MMS, online or phone unless stated otherwise.
Opt Outs: You have the right to refuse direct marketing and can do so by ticking the relevant box (es) below.
Consent: I am consenting to receiving information about the ASA/British Swimming initiatives from the ASA/British Swimming and their commercial partners by post, e-mail, SMS/MMS, online or phone unless I tell you otherwise.

No thank you, I don’t want British Swimming/ the ASA to send me details of products and services

No thank you, I don’t want British Swimming/ the ASA to send me details of events
No thank you, I don’t want British Swimming/ the ASA to send me details from British Swimming/ the ASA’s commercial partners
2.  Apprenticeship Specific (Use of Personal Data)
The Apprenticeships will utilise my personal data for the following purposes:
§  Post, e-mail, SMS/MMS, online, phone correspondence.
§  Sharing of information with my school/college.
§  Submission of personal data to the funding body.
§  Submission of personal data to other relevant bodies (sector skills council and awarding body).
§  Use of video, photographic evidence for the NVQ evidence portfolio and marketing & promotional materials.
§  Submission of data to the “Management Information Across Partners” (MIAP site).
Are you happy for the Apprenticeships team to utilise your personal data as described above? YES/NO
3.  Apprenticeships Specific (Correspondence method)
Are you happy to receive correspondence from the Apprenticeships team solely via e-mail? YES/NO
If NO, would you prefer to receive correspondence both via e-mail and post? YES/NO
Signature Section
Please sign below to confirm that you have read each of the sections listed above and that you are happy with the options you have selected.
1.  ASA/British Swimming/Institute of Swimming Data notice
2.  Apprenticeships Specific (Use of personal data)
3.  Apprenticeships Specific (Correspondence method)
ATHLETE SIGNATURE: DATE:

PLEASE RETURN COMPLETED ELIGIBILITY FORM TO THE FOLLOWING ADDRESS BY NO LATER

THAN 1ST JUNE 2010:

The ASA

4th Floor (Institute of Swimming-Apprenticeships Office)

SportPark

3 Oakwood Drive

Loughborough

LE11 3QF

E-mail:

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