PERSONAL DETAILS OF NOMINEE Nomination for Lifetime Achievement Award We will be taking photographs at The Awards Ceremony 2018 which may be used for publicity purposes on social media & Wirral Sports Forum website. You need to tell us if you have any concerns or questions about this. Office Use: Shortlisted: o o PERSONAL DETAILS OF NOMINEE   FULL NAME: AGE: ADDRESS: POSTCODE: CONTACT NUMBER: EMAIL:    SPORT: NAME OF CLUB: Summary of main achievements. Dedication and commitment to their sport e.g. hours given, years involved.

2. Support given to local club. 3. Developments made to the sport/club due to their input. 4. What do the club members say about this person? Please provide quotes. 5. Any additional information. I understand that if this nomination is successful I may be asked to; Provide evidence to support the information supplied Assist with the promotion of the Sports Bursary Scheme Attend next years awards evening NOMINATED BY: FULL NAME: CONTACT NUMBER: EMAIL: CONNECTION TO NOMINEE (coach, teammate, teacher, parent): To my knowledge all of the information provided is correct Signed: Date:

CLOSING DATE – Monday 30th July 2018 SUBMISSION NOTES Data Privacy Statement   The data will be kept by Wirral Sports Development on behalf of Wirral Sports Forum for the purpose of contacting previous shortlisted nominees to support future award ceremonies (for maximum of 12 months).  Data will not be shared with any third party. Checklist Have you completed all sections? Are your contact details correct? All information provided is relevant to the lifetime period CLOSING DATE – Monday 30th July 2018 To submit your nomination please email the completed form to davesimmonds@wirral.gov.uk Postal nominations should be sent to Dave Simmonds Community Sports Development Officer Wirral Sports Development Unit 1st Floor, Conway Centre Conway Street Birkenhead CH41 6JD Tel: 0151 666 4165 Mob: 07876 577 187. o o o