Government of Newfoundland and Labrador
Department of Tourism, Culture & Recreation
Premier’s Athletic Awards Program
Application Form
General Information
Athletes interested in applying for the Team Gushue Scholarship Award will need to complete the scholarship application which can be downloaded from the Sport Newfoundland and Labrador website www.sportnl.ca
Please note the application deadline date.
SPORT: ___________________________________________________________________________________________
Are you a registered member of a Provincial Sport Organization? “ Yes “ No
Do you compete in other sports? “ Yes “ No
If yes, what sport Level: “ National “ Atlantic “ Provincial
Surname First Name
Mailing Address (Street/P.O. Box) ( Address to which correspondence should be sent )
City/Town Postal Code
Telephone: (H) (W) E-Mail Address: ___________________________________
Parents / Guardians Names
Telephone: (H) (W) ______________________________________
“ Picture Enclosed (please ensure name is printed on the back)
Birth Date: \ \ “ Male “ Female
Year Month Day
Educational Status: “ Not Attending School “ Post Secondary (Year of Study _________
“ High School (Present Grade ___ “ Other
If Other, please specify: ______________________________________________________________________________
Employment Status: “ Full-time “ Part-time “ Presently Unemployed “ Student
For Post Secondary Student Athletes Only
Name of Institution: __________________________________________________________________________________
Faculty/Degree Program: Major: ___________________________________
“ Full-time Student “ Part-time Student Attending from: \ to \ ______ Month Year Month Year
Athletic Performance
PROVINCIAL PERFORMANCE |
EVENT |
DATE |
PLACING |
# OF ENTRIES IN COMPETITION |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
NATIONAL PERFORMANCE |
EVENT |
DATE |
PLACING |
# OF ENTRIES IN COMPETITION |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
INTERNATIONAL PERFORMANCE |
EVENT |
DATE |
PLACING |
# OF ENTRIES IN COMPETITION |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Estimate of Training Costs (Sept. 2006 - Dec. 2007)
Training Costs: (gym fees, personal trainer, special equipment, personal gym)
1. $ ___________________
2. $ _____________________
3. $______________________
Competition Costs: (Travel, Hotel, Registration Fees, etc.)
1. $ _____________________
2. $ _____________________
3. $______________________
Other Expenses: (equipment, tuition fees, additional living expenses, camps, etc.)
1. $ _____________________
2. $ _____________________
3. $______________________
TOTAL$______________________
* Attach additional information if necessary.
Present Funding Sources
Please list the sources of funding for your present training and competition costs including bursaries, scholarships, sponsorships, grants, remuneration or other financial assistance received for athletic or educational endeavours.
FUNDING SOURCE DESCRIPTION AMOUNT
$ _____________________
$_____________________
$ _____________________
$_____________________
Athlete’s Declaration
I hereby declare that the above information, to the best of my knowledge, is true and complete and that if selected, in return for any assistance provided under the Premier’s Athletic Awards Program, I undertake to fulfill all training and competition commitments and I agree to compete for the Province of Newfoundland and Labrador in Canada Games and other national level competitions.
________________________________
Applicant’s Signature Date
Any Additional Comments: ____________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________________________________________________________ ____
Please forward the completed application, including coach’s signature below, to your Provincial Sport Organization on or before December 14th, 2007.
FOR COMPLETION BY COACH ONLY
__________________________________________________________________________________________________ Surname Given Names
__________________________________________________________________________________________________ Current Mailing Address (Street/P.O. Box)
__________________________________________________________________________________________________ City/Town Postal Code
Telephone: (B) (H) ____________________________________
This will confirm that the applicant, , is presently training and competing in the sport
Name
of under the guidance and training of the undersigned.
Sport
________________________________
Coach’s Signature Date
Comments: ________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________
FOR COMPLETION BY PROVINCIAL SPORT ORGANIZATION ONLY
NAME OF PROVINCIAL SPORT ORGANIZATION: ________________________________________________________
Date application received by Provincial Sport Organization: \ \ _______
Year Month Day
Athlete’s ranking for assistance within your sport: (i.e. first, second, third, etc): ____________________________________ Male and female athletes must be ranked together.
_________________________________
Signature of President, Provincial Sport Organization Date
Checklist
Ensure the following are completed before submitting your application:
“ Picture enclosed
“ Application signed
“ Performance section completed
“ Coaches signature