UCI Soigneur Training Course

Course Application Form and Student Profile

To attend the Soigneur Training Course please complete this form and return it together with the relevant paperwork to the address overleaf. For further help and advice before you make a booking, please contact the Development Department (). This information will be used to register you onto the programme. The information will also be shared with the programme trainers and World Cycling Centre staff to enable them to provide a quality delivery and support for all students on the course.

* Mandatory information

Course Details* (please indicate below which course you wish to attend)

Course / Dates / Discipline / Language / Selected course
Course 1 / 5th August– 27th September 2013 / Soigneur / English

Personal Details

Title: * First Name: * Surname:

* Maiden Name:

(for women) * Gender: Female Male

* Date of Birth: Place of Birth: Marital status:

* Nationality: Religion:

* Postal Address:

Postcode: City: Country:

Tel no. (home): Tel no. (work):

Mobile: E-mail:

*Contact telephone number – you must provide at least one contact number, preferably a number that you can be contacted on during the day.

Important: please send us a copy of your passport!

Passport-No:

Date of issue: Valid until:

Excellent
1 / 2 / 3 / 4 / Poor
5
Spoken
Written
Reading

Level of English knowledge:

Mother tongue:

Student Profile

Please complete the following questions to help us to maximise your education experience. This information will be shared with the course trainer and World Cycling Centre staff, to enable them to provide a quality delivery and support for all students on the course.

Briefly outline your history/experience within cycling, including any experience as a Soigneur

List any other cycling courses / qualifications held (please attach copy of certificates)

List any relevant courses / certificates or qualifications, (eg sports massage, teaching, coaching qualifications etc)

My current cycling activities are:

My future activities as a Soigneur are likely to be:

My cycling specialisation is (discipline):

Why do you want to attend the Soigneur Training Course?

Any other information you feel we should know (including any specific dietary requirements)?

Prerequisite Documentation

I have attached the following compulsory documentation. I understand that my application will not be processed without these documents.

Course Application and Student Profile

Please provide full contact details below of who will be paying the fees on your behalf (if applicable). An invoice will be sent to them following receipt of the application.

Invoice to be made for the Attention of:

Postal Address:

Copy of your passport

Copy of your certificates (where applicable)

Candidate

Place and date: Signature:

Please return this application form and prerequisite documentation to:

UCI, Training and Development Department, 1860 Aigle, Switzerland

Fax: +41 24 468 58 12 E-mail:

4/4