Application Form- Regional
Please complete the form fully in block capitals and return to the relevant regional office/Local authority office; you must complete all
sections below to be accepted onto the course; these details are required in order to retain your qualification on the Scottish FA
database. Full payment must also be received with this application for you to participate in this course.
Title:
Mr
Mrs
Miss
Surname:
Ms
SFA ID Number (if known):
Name:
E-mail:
(This is essential as all correspondence for this course is via email)
Home telephone:
Daytime telephone:
Full address:
Postcode:
Date of Birth:
Place of Birth:
Club:
Quality Mark Club
Quality Mark Discount
tick if applicable
tick if you have been authorised to claim a QM discount
Please provide details of any medical conditions, disabilities, dietary requirements or specific needs:
Course/Event Details
(if applying for more than one course from different authorities, please complete separate forms for each authority )
Early Touches (£40)
Coaching Young (£55)
Coaching in the Game (£55)
Development Activities (£40)
Coaching Footballers 13+(£55)
Goalkeeping Certificate (£40)
Varies
CPD Event*
Venue:
Date of Event/Course:
* If Event please give name of event:
Payment Details
Cash:
Any other Event*
Cheque:
If paying by cheque please make payable to: CNES
Varies
Cost:
Application Form- Regional
Equity Monitoring
The Scottish FA is committed to promoting equality and eliminating discrimination. We seek this information for monitoring participation in football only
and will not use it for any commercial purpose or share it with any third party.
Please mark (X) in ONE box which best describes your ethnicity
□ White Scottish
□ Polish
□ Bangladeshi
□ African
□ Other British
□ Pakistani
□ Chinese
□ Caribbean
□ Irish
□ Indian
□ Arab
□ Mixed Race
□ If ‘other’ please specify:
□ Prefer not to say
Please mark (X) in ONE box which best describes your religious denomination
□ Christianity
□ Judaism
□ Hinduism
□ Islam
□ Buddhism
□ Sikhism
□ If ‘other’ please specify:
□ None
□ Prefer not to say
□ Yes
Do you consider yourself to have a disability?
□ No
□ Prefer not to say
Terms and Conditions
1. Applications should be received prior to course commencement .
2. Fees must be fully paid on application to secure a place on the course.
3. We reserve the right to cancel or amend the arrangements for any course. In this event, any course member unable to
transfer to an alternative course venue will be issued with a full refund
4. The validity of the coaching qualification is limited in time to 4 years. Unless you progress to another level within that 4 year
period you will be required to repeat the course and re new your qualification.
5. The Scottish FA is strongly committed to equal opportunities for all participants involved in its coach education programme.
It is the policy of the Scottish FA to ensure that all course participants receive equal treatment regardless of age, gender,
marital status, employment status, social class, colour, race, ethnic or national origin, religious belief or disability.
6. The course member agrees to abide by the rules laid down by the Scottish FA and its Staff
7. Your information will be used by the Scottish FA to maintain and update course attendance records
8. Quality Mark discount is only permitted if you are taking the course within your own region
9. Data Protection – This data will be maintained in accordance with the Data Protection Act 1998.
I have read and agreed with the Scottish FA's terms and conditions in respect of Coach Education
Signed:
Date:
Please return this form to:
Steven Munro
Community Sports Development Officer,
Sport and Health, Lewis Sports Centre,
Stornoway, HS1 2PZ
Tel: 01851 822 785
e-mail : [email protected]
If paying by cheque please make payable to: CNES
For Office use only:
Application Form Complete
Quality Mark
Yes
No
Payment Received: