Esperance Talent Development Application

Name

Date of Birth

Address

Street Address:*

City:*

State:*

Post Code:*

Country:

Mobile

Gender

Does the applicant identify as being of Aboriginal or Torres Island descent?

YesNo

Shire of Residence

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email

Sport in which you participate in or play

Name of contact person at SSA

Name of State Sporting Association (SSA) that is supporting your application

Position held at SSA

Email of contact person at SSA

Phone of contact person at SSA

Name of Coach

Email of Coach

Please describe your recent achievements in your sport and how you think you meet the scholarship criteria?

Describe your goals for the next 12 months

What can the Esperance Talent Development Centre do to help you achieve these goals?

Name of person completing this application

I confirm that the High Performance Manager or approved representative of the SSA and or the Regional Sports Assoc endorse and supports this application.

Yes

I certify that the information provided in this application is true and correct

yes

Esperance Talent Development Application

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