Athlete Profile

Surname *

(Required)

Forename *

(Required)

DOB (DD/MM/YYYY) *

(Required)

Gender *

Place of Birth *

(Required)

If POB outside NI how do you meet criteria to represent NI?

Country you represent *

(Required) Northern Ireland Ireland Great Britain

Occupation: Please tick which of the following you are involved with: *

(Required) School University Full time employment Part time employment Other

Please state the educational course or field of work that you are involded in:

Address *

(Required)

City / Town *

(Required)

County *

(Required)

Postcode *

(Required)

Mobile Number *

(Required)

Email Address *

(Required)

Athlete Facebook page

Athlete Twitter account

Emergency Contact Name *

(Required)

Emergency Contact relationship to athlete *

(Required)

Emergency Contact Email *

(Required)

Emergency Contact Address *

(Required)

Emergency Contact Mobile Number *

(Required)

Emergency Contact Daytime Number

Do you have private medical insurance? Please tick as appropriate *

(Required) Aviva BUPA VHI Other No Cover Unsure

If you have private medical insurance please select the date on which it expires (DD/MM/YYYY)

GP Name *

(Required)

GP Address