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Leadership Academy 2014 – 2015 Name

Gender

School

2014-2015 School Year

Home address

Leader’s email address Leader’s mobile number Parent/ guardian email address Parent/ guardian mobile number What is your clothing size? Were you involved 20132014 Leadership Academy?

XS

S

M

L

XL

XXL

What previous experience do you have of sports leadership? (please use additional sheet if necessary)

If you would like to apply to be one of our Elite Leaders, please explain why?

Would you like to be part of the Football Futures programme? Young Leader’s signature Parent/ Guardian’s signature

Date Date

I understand that in signing this application form I give consent for my son/ daughter to be involved in the Derby City SSP 2014 – 2015 Leadership Academy I DO/ DO NOT give consent for photos of my son/ daughter to be taken and used in promotional materials including web-based outlets (e.g. SSP website, twitter and facebook) Return complete forms to Liam Drake, Derby City SSP, c/o Derby County Community Trust, iPro Stadium, Pride Park, Derby DE24 8XL or email to liam.drake@derbycityssp.co.uk


Leadership academy 2014 2015 application form