<p> THE MICKEY BUSHELL DIVING SCHOLARSHIP - APPLICATION FORM</p><p>Please ensure that hand written applications are clear and legible. Please attach additional sheets if necessary.</p><p>1. YOUR DETAILS:</p><p>First name</p><p>Surname</p><p>Address</p><p>Postcode</p><p>Date of Birth</p><p>Email address</p><p>Home Telephone</p><p>Mobile Telephone</p><p>2. PARENT/GUARDIAN DETAILS (if under eighteen years of age, only)</p><p>Name of parent / guardian</p><p>Address if different from above</p><p>3. ABOUT YOU</p><p>What are your greatest achievements and successes, and how were you personally involved?</p><p>Immerse School of Diving, 24 Candleberry Meadow, Ketley, Telford, Shropshire, TF1 5TD Telephone: (+44)7773771619; Email: [email protected]; Website: www.immersediving.com What qualities and skills do you have that make you suitable for the Scholarship?</p><p>What interests you about the underwater world, and what makes you think that you will enjoy scuba diving?</p><p>Why would you like to be the Mickey Bushell Diving Scholar?</p><p>Immerse School of Diving, 24 Candleberry Meadow, Ketley, Telford, Shropshire, TF1 5TD Telephone: (+44)7773771619; Email: [email protected]; Website: www.immersediving.com What are your personal goals, and how will the Scholarship help you to achieve them?</p><p>How do you intend to raise awareness and further the aims of the Scholarship?</p><p>Any other information you would like us to know in support of your application?</p><p>Please describe your physical challenge, and any adaptive techniques you use in daily life.</p><p>Immerse School of Diving, 24 Candleberry Meadow, Ketley, Telford, Shropshire, TF1 5TD Telephone: (+44)7773771619; Email: [email protected]; Website: www.immersediving.com IMPORTANT: Please ensure that you have read carefully through the Terms and Conditions and Frequently Asked Questions before submitting your application. </p><p>All applications must be submitted together with a completed Medical Questionnaire (signed by your GP where applicable, and a parent or legal guardian if under eighteen years of age) to [email protected] or Immerse School of Diving, 24 Candleberry Meadow, Ketley, Telford Shropshire TF1 5TD, in each case marked ‘The Mickey Bushell Diving Scholarship’. We will acknowledge your application upon receipt, and respond in full as soon as possible (but please allow at least three weeks for a full response to your application).</p><p>Signed by the applicant Signed by the parent / guardian (if under eighteen years of age only)</p><p>Date Date</p><p>Immerse School of Diving, 24 Candleberry Meadow, Ketley, Telford, Shropshire, TF1 5TD Telephone: (+44)7773771619; Email: [email protected]; Website: www.immersediving.com</p>