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Quercus Sport Scholarship
Application Form 2017/2018
SECTION A: Personal Information*
NAME
DATE OF BIRTH
GENDER
CITIZENSHIP
COUNTRY OF BIRTH
HOME ADDRESS
TERM ADDRESS
(If applicable)
EMAIL
PHONE NUMBER (Home)
(MOBILE)
SECTION B: Academic Details
B.1 If you are a registered UCC student please complete:
UCC STUDENT NUMBER
PROGRAMME OF STUDY
RECENT EXAM RESULTS
Please list most recent
college exams and
include subject and
grade
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SECTION B: Academic Details (contd.)
B.2 If you are a potential new UCC entrant please complete:
CAO NUMBER
SECONDARY SCHOOL
Name and full postal
address
Dates of Attendance
From
To
NAME OF SCHOOL
PRINCIPAL
UCC PROGRAMME
PREFERENCES
Please indicate the
title(s) of the UCC
programme(s) for which
you are applying in
order of preference.
Degree Title
CAO Code
1.
2.
3.
4.
5.
SCHOOL EXAMINATIONS RECORD TO DATE
Please list most recent from Junior Certificate, Pre-Leaving Certificate, Leaving
Certificate or EU equivalent.
Title of Examination
Year of Examination
Subjects
Level of Exam
(H or O)
2
Grade
Level of Exam
(H or O)
Grade
SECTION B: Academic Details (contd.)
DETAILS OF FURTHER EDUCATION / PROFESSIONAL EDUCATION (IF ANY)
(Details to include Institution Attended, Period of Attendance, Name of
Programme results etc.)
_ _
IF APPLICABLE, PROVIDE DETAILS OF EMPLOYMENT SINCE LEAVING FULL-TIME
EDUCATION:
_ _
SECTION C: Sporting Achievements
(To be completed by all applicants)
APPLICANT’S MAIN SPORT
(Be specific and if a team sport, please indicate position):
_ _
NUMBER OF YEARS PARTICIPATING IN THIS SPORT
_ _
NATIONAL GOVERNING BODY
_ _
CONTACT NAME
_ _
POSITION HELD BY ABOVE
PHONE NUMBER
_ _
_ _
CURRENT CLUB
_ _
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SECTION C: Sporting Achievements (contd.)
(To be completed by all applicants)
NAME OF CURRENT
AND/OR
PREVIOUS COACHES
_ _
HOME ADDRESS
PHONE NUMBER
SECTION C: Sporting Achievements
(To be completed by all applicants)
Have you applied for High
Performance/ elite Athlete Entry status
before?
If yes, please state when and to which
institution:
Yes __
Are you on the Irish Sports Council’s
International Carding System?
Yes ____
Are you contracted to a National
Governing Body within your sport?
Yes ____
Have you received funding from any
other body?
Yes ____
If yes, please give details:
_____
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___
No __
___
_
No __
__
No __
_
No ___
__ __
_
SECTION C: Sporting Achievements (contd.)
(To be completed by all applicants)
PLAYING/ PERFORMANCE LEVEL:
Please tick the appropriate boxes to show all the level(s) at which you have
represented your sport i.e. been a competing individual or team member.
Supplementary Information e.g. age group, level of
LEVEL
TICK
School Team
_
Club Team
_
Regional
Development
Squad
_
team (e.g.1st XI), event/International attended and in
what year(s), whether in team or squad and number of
times selected.
_____
Age Group
County
Age Group
Province
Age Group
National
Senior County
Senior Province
Senior National
MOST NOTABLE LIFETIME SPORTING ACHIEVEMENTS
(please include personal best performances, finishing positions, competition dates,
age group and national rankings as appropriate)
_____
_____
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SECTION C: Sporting Achievements (contd.)
(To be completed by all applicants)
SPORTING ACHIEVEMENTS DURING 2015, 2016 & 2017 TO DATE
(please include personal best performances, finishing positions, competition dates,
age group and national rankings as appropriate):
_____
MAIN SPORTING ACHIEVEMENTS FROM PREVIOUS YEARS:
_____
ANTICIPATED COMPETITION/TOURNAMENT PROGRAMME IN FORTHCOMING
SEASON: (you do not have to include individual matches just the main
competitions in which you plan to be playing/competing):
Competition
Venue
Date / Month
_____
_____
_____
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SECTION C: Sporting Achievements (contd.)
(To be completed by all applicants)
WHAT ARE YOUR REALISTIC SPORTING AMBITIONS?
_____
AT WHAT REPRESENTATIVE LEVEL DO YOU EXPECT TO COMPETE IN YOUR SPORT
OVER THE NEXT 18 MONTHS? (Please provide evidence for your answer e.g.
inclusion within your National Governing Body’s development plans or
programmes, selection criteria etc.)
_____
WHAT IS THE HIGHEST LEVEL OF REPRESENTATION POSSIBLE IN YOUR SPORT?
____
HISTORY OF INJURIES (please give details of any sports injuries sustained within
the last 2 years that required medical treatment and/or prevented you from
taking part in your chosen sport):
_____
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Section D: Personal Statement
(To be completed by all applicants. 500 words max)
HOW WOULD BEING AWARDED THE QUERCUS SPORTS SCHOLARSHIP ASSIST YOU
IN ACHIEVING YOUR POTENTIAL IN YOUR SPORT?
WHAT LEVEL OF CONTRIBUTION AND COMMITMENT ARE YOU WILLING TO MAKE TO
SPORT AT UNIVERSITY COLLEGE CORK?
_____
HOW MIGHT SPORT AT UNIVERSITY COLLEGE CORK BENEFIT FROM YOUR
INVOLVEMENT IN THE QUERCUS SCHOLARSHIP PROGRAMME?
_____
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Section E: References
(Please attach both a reference in relationship to your Sporting achievements and
an Academic reference)
Name of Academic Referee
Academic Referee Position
Name of Sport Referee
Sport Referee Position
Please note that if you are shortlisted for interview in UCC in April/May, you
may submit a portfolio outlining your achievements in this field, submitted in
any suitable format beforehand.
(Submitted materials may not be returned to applicant)
Section F: Declaration
I certify that the information given in this application is correct. I have read and
understood the terms of reference of the Quercus Sports’ Scholarship programme. I
understand that UCC may withdraw any offer of a place, or discontinue the Quercus
Scholarship, where supplied information is found to be incorrect, misleading or falsified.
I also hereby undertake, if admitted to University College Cork, to observe and comply
with Student Rules all other regulations of the University.
Signature of Applicant:
Date:
Photograph:
Where did you hear
about the Quercus
Scholarships?
Return the completed application form, ensuring that you have signed the
declaration on this page, together with the necessary supporting documentation
by February 10th, 2017 to:
Photograph:
Quercus Talented Students’ Programme,
University College Cork
Distillery House, North Mall, Cork
Contact details:
353 21 4904688
[email protected]
ww.ucc.ie/Quercus
*All data collected under the application form will be subject to the data protection policy of UCC. A full copy of the
ww.ucc.ie/quercus
policy is available on our website: http://ocla.ucc.ie/dataprotection/index.asp. All queries in relation to this policy and
its provision can be made to the Information Compliance Officer: [email protected] or 021 -4903949
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