What was your 2015-2016 World Championship result or your 2015-2016 highest level of competition and result?
(Please list the competition name)
List your results at any other international events sanctioned by your International Federation (IF) in 2015-2016.
Notice
The personal information that you provide on this application is collected by the Ministry of Tourism, Culture and Sport (Ministry), and is subject to the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31. The collection of this personal information is necessary for the proper administration of the Quest for Gold – Ontario Athlete Assistance Program (OAAP), established under the Ministry of Tourism and Recreation Act, R.S.O. 1990, c. M.35. The information will be used by the Ministry to determine eligibility for grants, to evaluate the Quest for Gold – OAAP, and for other purposes related to the Quest for Gold – OAAP. It will also be disclosed to and used by other entities as described below for the purpose of promoting amateur sport, the Quest for Gold – OAAP, and the Quest for Gold Lottery.
For more information regarding the collection of this personal information, please contact:
Scott Cooper, Sport Consultant
Sport, Recreation and Community Programs Division
Ministry of Tourism, Culture and Sport
777 Bay Street, 18th Floor, Toronto, ON M7A 1S5
416-314-7692
Declarations, Consents and Acknowledgements
I hereby declare that the information in this application is, to the best of my knowledge, true and complete, as it pertains to the Quest for Gold - OAAP. In return for any assistance provided to me under Quest for Gold - OAAP, I agree to fulfill all training and competition commitments as set out in the Sports Organization – Athlete Agreement between me and my Provincial Sport Organization, Multi Sport Organization or National Sport Organization. I also agree to compete exclusively on behalf of the Province of Ontario at National Championship events and for Canada at International Championship events, for a period of one year from the date my grant is approved and acknowledge Ontario as my permanent place of residence on athlete profiles, Media Guides, PSO/NSO websites, and in similar types of public communications.
I consent to the exchange of my name, contact information and sport-specific personal information (including information about my participation in and funding under Quest for Gold - OAAP and/or any other athletic assistance programs) among the Ministry, Sport Canada, other federal and provincial ministries, Provincial Sport Organizations, Multi Sport Organizations, National Sport Organizations, and Ontario-wide sports entities funded by the Ministry (including the Canadian Sport Institute Ontario and the Coaches Association of Ontario), as required for the purpose of assessing my application or otherwise administering the Quest for Gold - OAAP.
If awarded Quest for Gold - OAAP funding, I consent to:
the unrestricted use of my name, hometown and list of athletic accomplishments, without charge, in Quest for Gold – OAAP promotional materials, broadcasts, press releases and other communications and publications issued by the Ministry, including publication on the Ministry’s internet site;
the disclosure of my name, contact information and list of athletic achievements to my local MPP; and
the disclosure of my name, contact information and list of athletic accomplishments to:
other Ontario ministries, without charge, as required for the purpose of promoting amateur sport; and
the Ontario Lottery and Gaming Corporation for use, without charge, as required for the purpose of promoting the Quest for Gold - OAAP and the Quest for Gold Lottery.
If awarded Quest for Gold - OAAP funding, I also consent to my Provincial Sport Organization, Multi Sport Organization or National Sport Organization providing the Ministry with personal information relating to my compliance with my Sport Organization - Athlete Agreement, for the purpose of administering the Quest for Gold - OAAP.
I acknowledge and confirm that I am solely responsible for making all necessary investigations with the National Collegiate Athletic Association (NCAA), or other athletic organizations as necessary, to determine whether receipt of assistance under the Quest for Gold - OAAP would negatively affect my status as an amateur athlete or my eligibility to receive athletic or academic scholarships. I confirm that the Ministry has given me no assurances and made no representations in this regard. I will not make any claims against the Ministry in this regard.
I also acknowledge and confirm that I am solely responsible for determining whether receipt of assistance under the Quest for Gold - OAAP would negatively affect my eligibility for income support from other scholarships, bursaries or student financial assistance programs, disability or other pensions, social assistance programs or other income support programs. I confirm that the Ministry has given me no assurances and made no representations in this regard. I will not make any claims against the Ministry in this regard.
I certify that:
the information given in support of this Application for a grant is true, correct and complete in every respect;
I accept sole responsibility for the expenditure of the grant funds; and
I have read and understand the information contained in this application form, including the terms and conditions attached to this application.
If you agree with all of these Declarations, Consents, Acknowledgements and the terms and conditions attached to this application, please indicate your acceptance of them by signing below. Signature of this form constitutes your acceptance of these Declarations, Consents and Acknowledgements, and the terms and conditions attached to this application, even if you have not read them.
Name of Applicant
Last Name
First Name
Middle Initial
Signature
Date (yyyy/mm/dd)
Name of Parent or Legal Guardian (required if applicant is under 18)
