Re-application for existing DIS athletes Athlete Details Personal Information Athlete Name (required) House Name/Number Street Town/City District ---Amber ValleyBolsoverChesterfieldDerby CityDerbyshire DalesErewashHigh PeakNorth East DerbyshireSouth DerbyshireNot from Derbyshire Postcode Contact Details Phone Number Email Address Confirm Email Social Media Twitter handle Facebook Instagram Athlete Gender ---MaleFemalePrefer not to say Athlete Date of Birth Athlete Disability ---DisabledNon-disabledPrefer not to say If you have indicated that you have a disability, please choose as many of the following options that apply to you: ---Deaf/hearing impairmentVisual impairmentPhysical impairmentLearning disabilityLearning difficultyOther Athlete Ethnic Group White BritishWhite EnglishWhite ScottishWhite WelshWhite IrishAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - ChineseMixed/Multiple Ethnic Group - White & Black CaribbeanMixed/Multiple Ethnic Group - White & Black AfricanMixed/Multiple Ethnic Group - White & AsianBlack/African/Black BritishBlack/Caribbean/Black BritishPrefer not to sayOther Name of your School, College or University (if applicable): Next Contacts Parent/ Guardian Details - (If athlete is under 18): Name Phone Number Email Address Coach Details Name Phone Number Email Address Sports Club Details Club Name Please provide contact details for someone from your sport's governing body who will be able to confirm your performances: Name Position Phone Number Email Address PreviousNext Sport Information Sport Information Olympic Sport ArcheryAthleticsBadmintonBoxinCanoeingCyclingEquestrianFencingGymnasticsJudoModern PentathlonRowingSailingShootingSwimmingTable TennisTaekwondoTriathlonWeightliftingWrestling Paralympic Sport BocciaDisability ShootingDisability Table TennisPara-ArcheryPara-AthleticsPara-CanoeingPara-CyclingPara-EquestrianDressagePara-RowingPara-SailingPara-SwimmingPara-TriathlonPowerliftingVI JudoWheelchair FencingWheelchair Tennis Winter Sport Figure SkatingShort Track Speed SkatingSkeletonSki and SnowboardPara Ski and Snowboard Please state which category/discipline(s) you compete in : PreviousNext Review of last season Which of the following performance targets were stated in your DIS agreement last season? Please tick all that apply and provide the details. Win a national championships medal ---Yes, achieved – please state which medal you won and when this took placeYes, but didn't achieve – please explain whyThis was not a performance target in my last agreement Please provide details Be selected by the NGB to compete internationally ---Yes, achieved – please state which international competition you took part in and what result you achievedYes, but didn't achieve – please explain whyThis was not a performance target in my last agreement Please provide details Gain selection onto a World Class Potential squad: ---Yes, achieved – please state which level you have been selected onto and what support services you are able to accessYes, but didn't achieve – please explain whyThis was not a performance target in my last agreement Please provide details PreviousNext Goals For 2017/2018 Which of the following performance targets are you aiming to achieve during 2017/2018 Win a national championship medal – when is this taking place and what medal are aiming to win? Be selected by the NGB to compete internationally – which international event are you aiming to receive selection for and when does it take place? Gain selection onto a World Class Potential squad – when does selection take place and please provide Goals for 2017/2018 the details of who will be able to verify your selection. Are you aiming to compete at the next Commonwealth Games, Winter Olympics or Summer Olympics? Please list the 3 main competitions that you are planning to compete in during 2017/2018 and state when they take place and your anticipated result. Please provide details of your long term sporting aspirations: PreviousNext Submit Please check that you have completed the application form as detailed as you can and ensure that all information is accurate and correct. Your application will be validated and assessed in July and you should expect to hear from us by mid-August.