ASA North East Grant Aid application form

All information is mandatory. This form will be returned to applicant if incomplete. Written signatures are not required please insert your name an e-version will constitute a signature. The ASA North East Region will use your personal data for the purpose of your involvement in the ASAPlease print Scheme. Ipage, complete submitting this form I am consenting to NER Grant Aid off this understand that by the relevant information for the receiving information about the ASA NER Grant Aid Scheme by application. applicant, and return with the grant post, email, SMS/MMS, online or phone unless stated otherwise.

Name of club swim21 accredited? Name of applicant Address of applicant (including postcode) Daytime phone number Email address Applicants ASA number Course discipline IOS venue of course Start date of course Name of Tutor Signed applicant

Billingham ASC

Yes
Maria Whyborne Leicester Way

Level of accreditation

Skill Development

Eaglescliffe

Stockton-on-Tees TS16 0LP

01642 659787
m.whyborne@ntlworld.com

536397
Safeguarding Children Northfield Sportsdrome

Applicants ASA Licence number Level

17th May 2011

Joan Hope

End date of course Cost of course Date

17th May 2011

35

M Whyborne

2nd July 2011

Tara
Address of club secretary (including postcode

Middlesbrough Road Guisborough TS14 8HY

Daytime phone number Email address Signed club secretary

dwilliams@dksarchitects.com
Debbie Williams
Date

2nd July 2011

If applicant is under 18 years of age then parent/guardian must countersign below Signed (parent/guardian) Date

Please note the guidance information available online. Complete this form both pages and email to: grantaidner@swimming.org

Date received Decision Amount of grant Sent to office

ASANER Oct 2010

Please complete the relevant information for the applicant, and return with the grant application
Ethnicity codes: Please as applicable

A C E G I K M O

White British White Other Asian Pakistani Asian Other Mixed White & Black Caribbean Mixed Other Black African Other ethnic group

B D F H J L N

White Irish Asian Indian Asian Bangladeshi Chinese Mixed White & Asian Black Caribbean Black Other

Disability codes: Please as applicable 00 No known disability 02 Blind/are partially sighted 04 Wheelchair user/have mobility difficulties

01 03 05 07 09

Dyslexia Deaf/have a hearing impairment Personal care support An unseen disability e.g. diabetes, epilepsy, asthma etc Information refused/not known

06 Mental health difficulties 08 Multiple disabilities

ASANER Oct 2010