TENNIS LEICESTERSHIRE CHARITABLE TRUST (Reg. No. 1142318)

DECLARATION (to be signed by the parent/guardian of the Junior Player)

Tennis Leicestershire Charitable Trust offers financial assistance to individuals up to the age of 19 years in the form of designated coaching/training programmes or as a financial contribution towards travel/accommodation expenses when competing in tournaments and/or competitions sanctioned by the LTA outside or within the County.

The Trust will only consider applications from people under the age of 19 who live in Leicestershire and wish to undertake coaching in the sport of tennis or enter tennis competitions but are prevented from doing so by theirs or their parents’ limited financial resources

As a parent/guardian, it is a condition of this application that you offer:

i)	support to the player by means of transport to/from the training/coaching centre or club; 

ii)	you develop a good working relationship with the coaches/trainers involved; 

iii)	you motivate and encourage the player throughout the coaching/training programme. 

You will not be entitled to change or alter the coaching programme for any reason. In the event that either you or your child fails to commit to the training programme at any time, any Award made, will be withdrawn and you may be asked to refund to the Trust the amount of the Award expended at the time of withdrawal.

The following CONDITIONS apply:

i)	The Selectors will recommend on the level of coaching/fitness/training the player should receive relative to his/her age; 

ii)	The player must attend all coaching/training/fitness and/or other sessions as approved by the Trustees at the times and on the days and for the duration as recommended by the Selectors. 

The following TERMS apply:

i)	The Trustees decide the amount of the Award and the conditions upon which the Award will be made; the duration of the Award; and the terms of the Award. Their decision is final and binding and they are not required to give reasons if the Application is refused or is deferred for further consideration 

ii)	The Selectors will advise on the type and level of coaching the player should receive and nominate the coach to carry out the player's coaching programme. The Selector is not bound to nominate the player's existing coach, or for coaching to be carried out at the player's own club. 

iii)	Either the Selectors or the Trustees can suspend, terminate, vary or alter the terms of the Award at any time if, in their opinion:- 

a)	the circumstances of the player or (if applicable) his/her parent/guardian materially change to such an extent that the coaching/training programme becomes untenable or unjustified; 

b)	the relationship between the coach/trainer and player becomes untenable; 

c)	the parent/guardian of the player requests the cessation of coaching/training programme for any reason; or 

d)	the player indicates or demonstrates that he/she: 

i)	no longer portrays the correct mental approach to the coaching/training programme; 

ii)	no longer has the commitment, desire or willingness, or is unable for any reason to remain on the coaching/training programme; 

iii)	refuses, or is late in attending coaching/practice sessions at the required times or on the days stipulated; or 

iv)	is disrespectful, rude or displays unacceptable behaviour to the coach/trainer at any time. 

I, the undersigned, being the parent/guardian of the Junior Applicant confirm as follows: l have read and fully understand the above Terms and Conditions and consent to them.

Signed: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _   PRINT FULL NAME  _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Dated: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

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APPLICATION FORM

TENNIS LEICESTERSHIRE CHARITABLE TRUST AWARD

Before completing this form, please read the following notes.

1.	ALL questions on this Application Form MUST be completed.  FORMS WHICH ARE INCOMPLETE WILL NOT BE 
ACCEPTED. 
2.	The criteria of the Trust Award depends on the financial circumstances of the parent of the junior player. 

3.	Applications for financial assistance to cover travel/accommodation to Tournaments MUST be accompanied with details and dates of the Tournaments to be played, the entry fees payable and an estimate of travel and accommodation costs to and from the tournaments. 

4.	This form, when completed, should be handed to the County Office.

5.	This form is to be completed in BLOCK CAPITAL letters and signed by the PARENT OR GUARDIAN for players under the age of 18 years. 
6	For players over the age of 18 years - this form can be completed and signed by the player 

Before completing this form you must agree to the terms and conditions on page 1. If your application is successful, a copy of page 1 will be returned to you with the decision letter

FULL NAME OF PLAYER ……………………………………………………………………………………………………..

Date of Birth ............................................... Age ………………………

School/College/University attending :  .………………………………………………………………………….........

Player's current rating (if any)	…………………………………………………………………………...........	
Name of player's tennis club	…………………………………………………………………………….........	

Name of player's current tennis coach  …………………………………………………………………………….........

LTA Licence Number of above coach  …. ………………………………………………………………………............

FULL NAME OF PARENT/GUARDIAN…..………………………………………………...............................................

ADDRESS ………………………………………………………………………....................................................................

............................................................................................		Post Code: ...............…………..……………….	
Home Telephone No.(including code)	........................................... Mobile: ………………………………………..............	
FOR PLAYER'S OVER THE AGE OF 16 IN PART OR FULL TIME EMPLOYMENT - STATE NAME OF EMPLOYER	
AND WEEKLY SALARY:			
EMPLOYER:.......................................................................................................................................................			
SALARY: £..................................	pw		

PART 1 - ABOUT THE PLAYER

1.	Is the Player a member of the Club stated above as at the date of this Application?	YES/NO

2.	Is the Player currently receiving regular coaching from the Club's Coach as stated above? 

YES/NO

3.	If NO - please give reasons 

4.	If YES - how many coaching sessions are taken by the player per week?	.    …..............

5.	What is the cost of CLUB coaching lessons per week?	£……..........

6.	Does the player receive other, or additional coaching elsewhere e.g. school /college /privately? 

YES/NO

7	If YES - give the following information:

(i)	Name of Coach(es)........................................................................................................

(ii)	Coach(es) LTA Licence No: ...............................	.........................................

(iii)	Frequency of coaching/number of sessions: .................................................   per week/month

(iv)  Place of other, or additional coaching:

(v)	Level or purpose of other or additional coaching	2

(vi)  Cost of additional coaching: £………………………………………..	per week /per month,	
(vii)	How long has the player received additional coaching?	....................months/years	
(viii)	!s the additional coaching provided by a school / college or privately?	YES/NO	

8.	If YES - please provide full details 

9.	Does the player's CLUB provide any concessionary or subsidised coaching or training sessions when 
the player is competing for his/her club?	YES/NO

10.  If YES - please complete the following:
i)	Frequency of concessionary coaching/training: ………………per week/per month			
ii)	Level of coaching :............................................	,........................................................	
iii)	Days on which concessionary coaching/training is provided:.............................................		
iv)	Name of Coach :...............................................	LTA......................................LicenceNo:		
v)	Number of concessionary coaching/training sessions......................................attended:		
vi)	Value of concessionary or subsidised coaching.................................	£	per session	

PART 2  - MEDICAL INFORMATION ABOUT THE PLAYER

Notes:
i)	The parent/guardian of the player must complete all sections below. Any ailments or disabilities 

disclosed will NOT influence the decision of the Trustees, but MUST be disclosed to comply with Health and Safety Regulations and the Young Persons Welfare Policy of Tennis Leicestershire Ltd. 

ii)	The Anti-Doping Policy of the LTA has been adopted by Tennis Leicestershire Limited. Appendix 4 of the LTA Rules will apply in respect of substances contained in pharmaceutical or medicinal products. The player / parent/ guardian must detail the composition of prescriptive medications to ensure they are not categorised as prohibited substances within the context of the LTA's Anti-Doping Policy. For further details of the LTA's Anti-Doping Policy and Prohibited substances, please contact your local tennis club. 

Please indicate on this form if you have been unable to obtain the information you require from that source. 

Anti-Doping Information obtained		Anti-Doping information not obtained	

Warning: The use of Salbutamol, Salmeterol, Terbutaline etc., are prohibited in non-aerosol form,but permitted by inhaler only to prevent and/or treat asthma and/or exercise-induced asthma. Codeine, Dextromethorphan, Dextropropoxyphene, Dihydrocodeine, Diphenoxylate, Ethylmorphine, Pholcodeine and Propoxyphene and Tramadol are permitted. Insulin is permitted to treat insulin dependent diabetes.

iii)	All medical information disclosed or declared will be maintained in the strictest confidence. 

1.	Does the player suffer at any time from asthma / hay-fever / sinitus / rheumatism /arthritis / low or high blood pressure / migraine / repetitive headaches /diabetes or any other ailment for which he/she takes 
prescription/non-prescription medication.	YES / NO

If YES : give full details of the ailment and medication taken. You must give the trade or pharmaceutical name of the medication prescribed/taken and list its ingredients.

2. Has the player been medically diagnosed as suffering with heart, lung, kidney or liver deficiency OR is he/she receiving, or has he/she received, medical treatment for any of the above conditions in the last 12
months?	YES / NO

If YES: give full details of the complaint and the treatment/medication prescribed

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3.	Has the player undergone any surgical procedures in the last 3 years?	YES / NO

If YES: give full details

4.	Does the player suffer any form of mental, muscular or skeletal disability, impaired vision or hearing? 

YES/NO

If YES: give full details of the impairment or disability, and of any treatment currently undertaken, or special needs required:

MEDICAL FITNESS DECLARATION:

Delete as appropriate:

I, BEING THE PLAYER OR PARENT/GUARDIAN OF THE PLAYER DECLARE AND CONFIRM THAT:

i)	I have disclosed all known past and current medical conditions in respect of the junior player; 

ii)	I have disclosed all prescriptive and/or non-prescriptive medication used or taken orally by the Player; 

iii)	I have disclosed all ingredients contained in prescriptive and/or non-prescriptive medications taken by the player 

iv)	I believe the player to be medically fit and physically able to participate in tennis coaching/training programmes which may be more physically demanding and intensive than he/she has 
previously experienced.; and 
v)	I confirm the replies and information given on this form are true and correct 

Player / Parent /Guardian's signature: ……………………………………………………………………………………..

Please note: The Trustees reserve the right to require further information of medical complaints/conditions disclosed.

PART 3 – FINANCIAL AND PERSONAL

1.  Identify your current salary level:				
Husband:	Up to	£18000	£30000	£45000	£60000	Over £60000	
Wife:	Up to	£18000	£30000	£45000	£60000	Over £60000	

2. State your occupation and name of employer: 
    Husband’s

……………………….…………………………………………………………………………………
Wife’s

………………………………………………………………………………………………………….

3.	How long have you been employed by the above employer? Husband ……. Wife ……  
4.	Identify your status: Married / Single / Separated / Divorced 

5.	How many children do you have OTHER THAN the player named in this application ……
6.	If applicable, do you provide coaching for your other children  YES/NO 

Note: The parent/guardian/player will be expected to arrange/provide transport to and from tournaments and competitions stipulated by the Selectors and, where necessary, overnight accommodation. You are expected to discharge the full cost of overnight accommodation (where required) and provide all meals as necessary.

DECLARATION AND CONFIRMATION I, BEING THE PLAYER / PARENT / GUARDIAN (DELETE AS APPLICABLE) AND THE PERSON WHO HAS COMPLETED THIS FORM, CONFIRM I HAVE READ AND FULLY UNDERSTAND THE TERMS AND CONDITIONS WHICH I AGREE TO COMPLY WITH. I FURTHER CONFIRM THAT THE ANSWERS I HAVE GIVEN IN THIS APPLICATION FORM ARE TRUE AND CORRECT.I AGREE NOT TO MAKE CONTACT WITH THE SELECTORS OR THE TRUSTEES OF TENNIS LEICESTERSHIRE LIMITED WHILST THIS APPLICATION FORM IS BEING CONSIDERED.

Signed: .......................................................	Dated: …...........................................

PRINT FULL NAME: …………………………............................................................................................

THIS FORM MUST BE RETURNED TO THE COUNTY OFFICE –LEICSTENNIS@GMAIL.COM	4

TO BE COMPLETED BY THE TRUST SELECTOR

SELECTOR'S RECOMMENDATIONS:

Give reasons for the Award you have suggested and provide full information to support your recommendations.

TERMS OF AWARD

AWARD FOR COACHING/TRAINING :  Name of Coach ................................................................			
LTA Licence No:.................................		Coaching Period: ..................	weeks/months	
Venue:........................................................	No. of sessions :................	WEEKLY/FORTNIGHTLY/MONTHLY	
For:  30 / 45 / 60 minutes per session		Cost per Session :£...............................		
RECOMMENDED VALUE OF AWARD :£...................	,................			

Selectors: The value of the Award will be paid directly to the Coach AFTER all coaching sessions have been completed and the Trustees are in possession of the Coach Report which must give comprehensive information on the progress made by the junior player.

APPLICATION PASSED TO TRUSTEES ON (date)......................................

SIGNED (Selector)....................................................

For Trustees use only

TRUSTEES DECISION:	APPROVED / REJECTED / DEFERRED to (date)

UNANIMOUS / BY MAJORITY - VOTES FOR: ...................... VOTES AGAINST: ………………………

TOTAL VALUE OF AWARD £.

CONDITIONS OF AWARD

PARENT/GUARDIAN CONDITIONS:.

SIGNED............................................. (NAME)  ………………...................................................... ON BEHALF OF TRUSTEES.

DECISION LETTER TO APPLICANT SENT ON:……...................................................................

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