Coaching Scholarship Application Form – Midwest Academy of Sport

Name

First Last

Mobile phone number

Address

Email address

Applicants email address

Date of birth of applicant

Gender*

Male
Female

Applicant identifies as being of Aboriginal or Torres Straight Island descent?

Yes
No

Shire of residence

Included shires: Carnamah, Chapman Valley, Coorow, Cue, Greater Geraldton (includes Mullewa), Irwin, Meekatharra, Mingenew, Morawa, Mount Magnet, Murchison, Northampton, Perenjori, Sandstone, Three Springs, Wiluna and Yalgoo. (Athletes who go to a boarding school outside of the listed LGAs are not eligible for a scholarship).

Sport in which you coach or officiate?

State Sporting Association supporting the application (E.g. WACA, Basketball WA, Athletics WA, Football West)

State Sport Association (SSA) approving this application (Contact with and approval from the SSA must be obtained by the applicant prior to submitting this application). The SSA must be made aware of and support the applicant with the conditions of the scholarship – if unsure please ensure they contact MWAS CEO on 0487 846 283 or email mwas@sportshouse.net.au for details.

Name of contact person

Please provide the name of the person who has verified and supports the application on behalf of the SSA. This person will be required to liaise with the MWAS CEO throughout the period of the scholarship.

Position held at the SSA

The position held at the SSA could include the High Performance Manager, State Team Coordinator or Development Pathway Coach?

Email address

Telephone numbers

Please include office and mobile numbers.

Regional Sport Association (RSA) that is a partner in this application (If applicable)

Include this if your SSA will collaborate with the RSA to provide technical and tactical coaching to athletes, and/or if the RSA will invest any finances for the development of coaches or officials on scholarship.

I confirm that the High Performance Manager or approved representative of the SSA and/ or the RSA endorse and support this application.*

Yes, I confirm

The SSA must approve this application and support it.

Does the applicant have a disability / impairment? If so, please specify details.*

Yes
No

Coaching Applicants

Please provide a statement clearly demonstrating the relevant qualifications, coaching resume including teams/athletes you are currently coaching and also identify your coaching goals for the scholarship period if accepted into the program (bullet-points are acceptable).

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

Yes, I confirm the information that I have provided in this application is true and correct.