PERSONAL DETAILS OF NOMINEE Nomination for Special Recognition 2019 WIRRAL SPORTS FORUM AFFILIATED MEMBERS ONLY 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: WSF Member o o PERSONAL DETAILS OF NOMINEE   FULL NAME: ADDRESS: POSTCODE: CONTACT NUMBER: EMAIL: DATE OF BIRTH: AGE: SPORT: NAME OF CLUB: ALL INFORMATION GIVEN IN THE REMAINDER OF THE NOMINATION MUST RELATE TO THE PERIOD 1st AUGUST 2018 – 31ST JULY 2019  Summary of reason for nomination

2. Type of involvement in the sport. 3. Number of years involved. 4.Regular commitment to the club in terms of hours/duties. 5. What do the other club members say about this person? Please provide quotes. 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 period 1 AUGUST 2018 – 31ST JULY 2019  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