PERSONAL DETAILS OF NOMINEE Nomination for Lifetime Achievement Award 2019 We will be taking photographs at The Awards Ceremony 2019 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 – Wednesday 31st July 2019 SUBMISSION NOTES Data Privacy Statement The data will be kept by Wirral Council Sports Development on behalf of Wirral Sports Forum for the purpose of contacting previous shortlisted nominees to support future award ceremonies (for a maximum of 12 months).  Data will not be shared with any third party. Please refer to The Wirral Sports Forum website for our full statement on GDPR compliance. www.wirralsportsforum.co.uk   Checklist Have you completed all sections? Are your contact details correct? All information provided is relevant to the lifetime period CLOSING DATE – Wednesday 31st July 2019 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