Gwynedd Gold Card Application Form All sections must be completed, please follow the guidelines in the Application Pack

Transcription

1 Gwynedd Gold Card Application Form All sections must be completed, please follow the guidelines in the Application Pack Personal Details Title: Mr Mrs Miss Name: Address: Postcode: D.O.B: Mobile: Are you a member of a Leisure Centre in Gwynedd? Yes No Age: If you are, what is your membership Number? (If not you will be required to complete the Membership form ADH764) Club Details Your Sport: Your Local Club s Name: Where is the Club based? How long have you been a member? (years) Website: Your Sport / Squad How long have you been particiapting in your Sport? Is your National Governing Body of Sport recognised by Sport Wales? Yes No Are you a member of a National Governing Body National Squad for your Sport? Yes No Please Specify: Your Achievements North Wales Squad representation or Ranking Tournament from the last 12 months Event / Fixture Venue Date Achievement GN (years)

2 What are your aims for the next 12 months? Checklist (please tick) Have you kept a copy of the application for yourself? Have you attached a supporting letter from your Coach/Regional/National Squad? Have you enclosed a recent passport photo of yourself? Have you enclosed the Gwynedd Leisure Centre Membership form (if a non-member) Have you enclosed a cheque for 5? (Payable to Cyngor Gwynedd ) Declaration The information on this form is true and accurate to the best of my knowledge. I agree to abide by all the conditions set out in this application pack. Signed: Date: This section should be completed by your Regional / National Squad Coach / Manager or the Regional Development Officer for your Sport. Coach / Officer s Name: Role within Regional / National Squad: N G B: National Governing Body (NGB) Details Position in NGB: I have read the above information and confirm to the best of my knowledge that the applicant has provided accurate information. Signed: Date: Data Protection Act 1998: Gwynedd Council is the data controller for the purposes of the above Act. The information provided on this form will be used for the Leisure Service s purposes. It can be disclosed to other departments within the Council and other relevant agencies in accordance with the Councils registration under the Act. Could you please indicate whether you would be prepared to feature in any publicity regarding the Gwynedd Gold Card Scheme? Yes No Return this form to: Community Sport Development Officer, Cyngor Gwynedd, Dwyfor Area Offices, Embankment Road, Pwllheli, Gwynedd, LL53 5AA.

3 CYNGOR GWYNEDD COUNCIL GWASANAETH CANOLFANNAU HAMDDEN / LEISURE CENTRES SERVICE FFURFLEN GAIS AELODAETH / INDIVIDUAL APPLICATION FORM ADH674 Teitl / Title Enwau cyntaf / First Name(s) Cyfenw / Surname Dyddiad Geni / Date of Birth Cyfeiriad / Address Nifer plant / No of Children Côd Post / Post Code Ffôn Cartref / Home Tel No. Ffôn Gwaith / Work Tel No. e-bost / Rhif Aelodaeth / Membership No. GN MANYLION AELODAETH / MEMBERSHIP DETAILS Nodwch gyda pa fath o aelodaeth a ddymunwch / Please indicate with a which type of membership you require 1. Aelodaeth Oedolyn Preswyl / Adult Resident Membership Aelodaeth Iau Preswyl / Junior Resident Membership Am ddim/free 3. Aelodaeth oed / Membership Aelodaeth Dros 60 / Anabl / Over 60 / Disabled Membership Aelodaeth Oedolyn di-breswyl / Adult Non-Resident Membership Aelodaeth Iau di-breswyl / Junior Non-Resident Membership Aelodaeth Clybiau Oedolion / Adult club membership Aelodaeth clybiau iau, anabl, 60+ / Junior, disabled or 60+ club membership Aelodaeth Cerdyn Aur Gwynedd/Gogledd Cymru Gold Card Membership Am ddim/free Carwn ymgeisio am aelodaeth. Deallaf y bydd y cerdyn hwn yn dal yn eiddo i Gyngor Gwynedd ac y bydd yn ddilys am 12 mis. Cytunaf i lynu wrth amodau defnyddio r cerdyn. I wish to apply for Membership. I understand that the card will remain the property of Gwynedd Council and that it will be valid for 12 months. I agree to abide to the conditions of use of the card. Arwyddwyd / Signed. Dyddiad / Date. (Rhiant/Gwarcheidwad i arwyddo ar ran rhai sydd dan 16 oed) (Parent/Guardian to sign on behalf of persons under 16 years) Defnydd Swyddfa / Office use only Rhif / No: Deddf Diogelu Data 1998: Cyngor Gwynedd yw r rheolwr data at ddibenion y Ddeddf. Defnyddir yr wybodaeth ar y ffurflen hon at ddibenion y Gwasanaeth Hamdden. Gellir ei datgelu i adrannau eraill o r Cyngor ac asiantaethau perthnasol eraill yn unol â chofrestriad y Cyngor dan y Ddeddf. Data Protection Act 1998: Gwynedd Council is the data controller for the purposes of the above Act. The information provided on this form will be used for the Leisure Service s purposes. It can be disclosed to other departments within the Council and other relevant agencies in accordance with the Council's registration under the Act.

4 Applicant Guidelines Follow these guidelines in order to complete this form The Gwynedd Council Gold Card Scheme provides assistance to talented athletes in Gwynedd, representing North Wales. The scheme offers successful applicants access to Local Authority leisure facilities for fitness and training purposes within Gwynedd. HOW DO I APPLY? 1. Read through the eligibility, terms, conditions and booking conditions carefully to ensure that you are eligible. 2. Complete the application form. 3. A Regional Development Officer or a National Officer of the National Governing Body for your sport must sign the application form. 4. Copies of squad invitation letters or other supporting evidence of your achievements should support you application. 5. Return your application to the Sports Development Officer at the contact address provided in the pack, with a recent passport photograph and a cheque for 5 payable to Cyngor Gwynedd. ELIGIBILITY Applicants must live in Gwynedd. If you live outside Gwynedd you may apply for a card, but you must show that you compete as a regular member of a club in Gwynedd. An applicant must be a current member of a National Governing Body in a North Wales team or squad. This needs to be supported by copies of squad invitation letters and other supporting evidence of your achievements. Applicants, whose sports do not have North Wales fixtures and/or compete as an individual, must have finished in the first three positions of a North Wales Championship, organised by the National Governing Body of sport, in the last 12 months. Your governing body of sport must be recognised by Sport Wales. The Local Authority reserves the right to consult any organisation either local or national in connection with this application in order to assess the applicant's progress and current competitive status. The Local Authority reserves the right to refuse to give a Gwynedd Gold Card. If there is no North Wales Squad within your sport, please contact the Sport Development Officer. There are no age restrictions for applications.

5 TERMS AND CONDITIONS Entitlements i. Dependant on age and conditions at leisure centres, all fitness activities are available. ii. Swimming and the use of the athletics track at Treborth, Bangor is available to all. In other specific sports e.g. squash, the courts are available subject to conditions on your card. iii. The hire of courts are for training purposes only (no coaching). If the relevant criteria are met a Gold Card will be given. The successful applicant is the only one who can use the card. This card is non-transferable. The cardholder must comply with the rules and regulations for the facilities being used The availability of the facilities depends on the request in the application form and must be relevant to the applicant s training programme/sport. The card can only be used for training purposes. The card is not to be used for centre of developments/excellence, squad or private organisation training to reduce the costs for others. Applicants must provide a recent passport sized photograph and a cheque for 5 with their application. The card is valid for 12 months from the date of issue; you will need to return your card and completed evaluation forms to re-apply for the next 12 months. The card is non-transferable. If the card is misused, the Local Authority reserves the right to withdraw the Card, e.g. The card cannot be used to access a pool fun session. New benefits are continually being negotiated and cardholders will be notified accordingly. Incomplete forms will be returned, so that all the information can be provided. You must include all supporting letters, photos, and appropriate signatures. You should keep a copy of all documentation you send to us, so you have a copy for your own records. The cardholders must have an induction for some facilities, eg. Fitness Suites. BOOKING CONDITIONS Facilities that do not need to be booked in advance can be accessed at all times subject to opening hours/session nature, e.g. swimming. ONE session/court can be booked in advance per week. On other occasions, the cardholder may prebook 24 hours in advance or turn up on the chance that the facility is available. If the card is misused it will be withdrawn. Age restrictions on some facilities / activities apply, e.g. fitness suites, weights rooms. Cardholders will be required to confirm this prior to use of the facilities. All bookings are at the discretion of the manager. Cardholders must book in at reception for each visit and should phone the facility before use.