Please Return Application Form and Pre-Requisite Evidence Where Applicable To
EDE 20171 B
Course Venue:Cluarankwai Judo Club, 21 New Mill Road,Kilmarnock. KA1 3JB
Course dates:7th /8thOctober 2017 / Expected completion date:19th November 2017
Candidate Name (As it is to appear on certificate)
Mr, Mrs, Ms, etc. / First Name(s) / Surname
Candidate Personal Details
Date of Birth / Nationality / Maiden Name (if applicable) / Gender ()
M □ F □
Home Telephone / Work Telephone / Mobile Telephone
Email address
Candidate Home Address / Candidate Previous Home Address
SQA Details
Enter your 9 digit SQA Scottish Candidate Number (if known) / Scottish Candidate Number (SCNs) are allocated to candidates by SQA. This number is a unique candidate identifier and is required for SQA registration purposes. If you think you have previously been allocated a SCN by the SQA, this 9 digit number will appear on any SQA certificates you may hold. If you cannot find your certificates, your SCN can be checked for you (using name, date of birth and address) by calling the SQA Customer Contact Centre on 0845 279 1000. Please inform the PGA programme co-ordinator as soon as possible once your SCN becomes known to you. Alternatively, the PGA can track an existing SCN by using your name, date of birth and address.
Tick box if you have forgotten your SCN
Tick box if you have never had a SCN
Please state the name of your most recent training provider of SQA qualifications(e.g. Secondary School, College, University, S/NGB,Employer, None)
*Complete this section on course.
Induction information covered (Please tick appropriate boxes to confirm)
Equal Opportunities / Grievance Procedures / Appeals Process
Assessment Processes / Data Protection / Plagiarism
Candidate Remediation / Health & Safety / Alternative Special Assessment Arrangements
- I confirm that I have read and understood my personal responsibilities in respect of the above policies as detailed within the course processes. These policies and the support available from the centre were also explained during my induction.
- I give permission for my personal details to be forwarded by the centre to SQA for registration and data entry purposes.
- I also confirm that the evidence which will submitted by me is wholly my own work.
Candidate Signature Date / Delivery Staff Signature Date
SQA OFFICIAL USE ONLY
Date received / Date Candidate Filed / Date Unit Filed / Date Green
Notes / Notes / Notes / Notes
Pre –requisite information
Candidate Name / Club:
JudoScotland (JS) Membership No. / Membership Expiry Date: / If not JS member then name of Judo Association you are affiliated to:
Please tick to indicate that you have attached evidence of the following compulsory pre-requisite requirements:
LEVEL 1 / LEVEL 2 / LEVEL3
Be at least 17 years of age / Be at least 18 years of age / Be at least 21 years of age
Hold a minimum BJA Grade 2nd Kyu / Hold a minimum BJA Grade 1st Kyu / Hold a minimum BJA Grade 1st Dan
Please tick the box to indicate you have included two passport sized (recent) photographs of yourself to retain on our database.
Coaching commitment (Please provide information on your current/planned coaching activity)
How many years have you participated in Judo? / ……………years
What is your Judo grade? / …………Kyu/Dan
Do you have any competitive experience, if so what level? (delete as appropriate) / club / county /area / national / international
Roughly, how many years have you coached or assisted prior to this course? / ……………years
How many times a week do you presently coach or assist? / ………….per week
In future, how many times a week would you like to coach? / ………….per week
Which Local Authority area does your coaching activity take place?
Please list any other coach awards / certificates and or qualifications you have gained.
Supporting Statement. By achieving this qualification please describe what impact this will have on the school, club or community you will be coaching in.
Disability
Do you consider yourself to have a disability? / Yes / No / Prefer not to say
Hearing / Physical / Other, please provide further details if any support is required.
Visual / Mobility
Learning / Multiple
Ethnicity: I would describe my ethnic origin as:
Asian British Bangladeshi / Black African / Mixed white & Black Caribbean / White European
Asian British Indian / Black British / Mixed white & Asian / White Non-European
Asian British Pakistani / Black Caribbean / Mixed white & Black African / Other White
Other Asian / Other Black / Other Mixed background / Prefer not to say
Pakistani / Chinese / White British
Indian / Bangladeshi / White Irish
Full payment must be received at time of application. Course fees for UKCC level 1 are £260, funding assistance of up to 40% can be applied for through SportScotland. Please see website for further details
Payment Details:Cheque / Visa / Mastercard / Switch / Delta
Cheque amount:
£ / Account Name: / Account number:
Credit/Debit Card No.
Account Name / Valid from / Expiry date / Issue No.
Signature: / date / 3 digit security code
Please return application form and pre-requisite evidence where applicable to:
, JudoScotland, EICA-Ratho, South Platt Hill, Newbridge, EH28 8AA