Inspiration for Sport

Rowing

APPLICATION FORM
(Please complete application form in BLOCK CAPS)

PERSONAL DETAILS

NAME: _____________________________________________

HOME ADDRESS: _____________________________________

___________________________________________________

HOME NUMBER: _________________________ DATE OF BIRTH: _________________
MOBILE NUMBER: ________________________EMAIL ADDRESS: ___________________________

CLUB or SCHOOL NAME: ______________________________________

CLUB or SCHOOL ADDRESS: _______________________ SCHOOL NO: _________________

_______________________

_______________________

GCSE / JUNIOR CERT RESULTS: (Please enclose a copy of your GCSE / JNR CERT results)
SUBJECT                                              GRADE                  SUBJECT                                              GRADE
______________________    ____________      ______________________    ____________
______________________    ___________        ______________________    ____________
______________________   ____________       ______________________    ____________
______________________    ____________      ______________________    ____________
______________________   ____________       ______________________    ____________

_____________________   ______________    _______________________  ____________

AS LEVELS or LEAVING CERT (If repeating)
SUBJECT                                              GRADE                  SUBJECT                                              GRADE
______________________    ____________      ______________________    ____________
______________________    ___________        ______________________    ____________
______________________   ____________       ______________________    ____________
______________________    ____________      ______________________    ____________
______________________   ____________       ______________________    ____________

A LEVELS / LEAVING CERT (PREDICTED)
SUBJECT                                              GRADE                  SUBJECT                                              GRADE
______________________    ____________      ______________________    ____________
______________________    ___________        ______________________    ____________
______________________   ____________       ______________________    ____________
______________________    ____________      ______________________    ____________

Interested in going to University?   YES/NO          Which subject area(s) ________________________

Rowing profile
(Tell us about your rowing career to date)

__________________________________________________________________________________

Your Coaches

Name:                                                   Ph No:                                   e-mail:

______________________________________________________________________________

ROWING ACHIEVEMENTS:
Please list any rowing results you have recorded over the last few years which you believe may be of interest to us.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

OTHER INFORMATION:
Please let us know why you should be awarded a place on this one day Inspiration for Sport Event (Rowing) at Queen’s University Belfast, and what course you would like to pursue.
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLEASE RETURN THIS APPLICATION FORM NO LATER THAN WEDNESDAY 2 OCTOBER 2013 AT 12PM.

RETURN TO;

Natalie Chambers

Queen’s Sport

Physical Education Centre

Botanic Park

Belfast BT9 5EX

or

e-mail:  n.chambers@qub.ac.uk

Enquiries to; Mick Desmond m.desmond@qub.ac.uk   +44(0)7588277121 or Anthony McGrath a.mcgrath@qub.ac.uk

QUB open day Sunday 6th October - anyone possibly interested in applying to Queen’s next year please contact Keith Leighton Club Captain.

September 22nd, 2013