邢唷> 欹K !bjbj 8貇8i貇8iSwxxxxx8d(Ty,&|( +++++++.U1+x " " "+xxX,*W&W&W& "Fxx+W& "+W&W&4)€)€吹:徬O"L)+=,<y,T),2U#2€)2x€)h 0 "W& !(! ++%B y, " " " "2 X >: APPLICATION FOR STRETCHED DEGREE APPROVAL Academic Registry Student Records & OperationsThis form is an application to stretch your degree for the purposes of pursuing elite sporting activities. Please complete in conjunction with Stretched Degree Policy. For Office Use Only Initial enquiry to SDC Form submitted to SDC by student Form returned to Student by SDC Form submitted to Department by Student Form sent to SRO by department Date Initials Date Initials Date Initials Date Initials Date Initials  Part One To be completed by the Student1. Name2. ID Number3. Email Address4. Department5. Current Programme6. Year of Study To Be Stretched (e.g. third year)7. Period of Time Covered by Application (e.g. 2010-2012)8. Sport9. Highest Level of Achievement to date 10. Please provide details of the specific reason why you wish to reschedule your academic programme. You should have a realistic opportunity of competing at senior international level in your sport within 18 months of commencing a stretch degree study mode, or be aiming for a specified major international event (e.g. World Student Games, European Championships, World Championships, Commonwealth Games or Olympics). 11. This request should be accompanied by a supporting statement. Normally this would come from the University Director of Sport; if this isn抰 appropriate then please ask your NGB to complete the Supporting Statement and tick the box once its attached. (12. STUDENT DECLARATION I confirm that the above information is correct and fully understand the implications of my request to stretch this year of my programme. These could include those relating to reassessment and/or progression on to a further part of my degree programme. I also understand there could be financial implications in relation to support from my Local Authority and the Student Loans Company. I understand that undertaking a stretched degree alone will not normally be sufficient grounds for a claim for impaired performance at a later date. I understand that a stretched degree is a privilege and not a right and that the final decision rests with my academic department. Signature: Date: / /  Part Two To be completed by the Sports Development Centre13. The Sports Development Centre DOES / DOES NOT support this REQUEST (please circle as appropriate) Please note this is a request; the final decision remains with the academic department.14. Do you believe the athlete has a realistic chance to achieve the performance goals in Section 10? YES NO 15. To be completed by the University Head Coach Please provide comments/reasons for support of this application: 16. UNIVERSITY HEAD COACH DECLARATION I confirm that the above information is correct and that I have fully discussed the implications of a stretched degree with the student Print Name: Signature: Date: / / 17. To be completed by the Deputy Director of Sport or designated nominee Please provide comments/reasons for support of this application: 18. DECLARATION by 厖厖厖厖厖厖厖厖厖...(insert job title) I confirm that the above information is correct and that I have fully discussed the implications of a stretched degree with the student and their coach Print Name: Signature: Date: / /  Part Three To be completed by the Academic Department19. The Department of DOES / DOES NOT support this application (please circle as appropriate)20. To be completed by the Student抯 Personal Tutor Please provide comments / reasons for support of this application: 21. Proposed schedule of modules recommended by the Department:First Year of Stretch: Year 20 - 20 :Semester One Modules Credit WeightingSemester Two Modules Credit WeightingTotal Credit Weighting for Year One: Second Year of Stretch: Year 20 - 20 .Semester One Modules Credit WeightingSemester Two Modules Credit WeightingTotal Credit Weighting for Year Two:22. PERSONAL TUTOR扴 DECLARATION I confirm that the above information is correct and that I have fully discussed the implications of a stretched degree with the student. Print Name: _______________________________________ Signature: ______________________________________ Date: ____ / _____ / _____23. HEAD OF DEPARTMENT DECLARATION I confirm that the above information is correct Print Name: _______________________________________ Signature: ______________________________________ Date: ____ / _____ / _____ Part Four Request for a Waiver of Programme Regulations A REQUEST FOR A WAIVER OF PROGRAMME REGULATIONS IS HEREBY SUBMITTED TO THE ACADEMIC REGISTRY (via SR&E Office) AND IS EFFECTIVE ONCE APPROVED BY THE RELEVANT AD(T) 24. ASSOCIATE DEAN OF TEACHING扴 DECLARATION I confirm the above information is correct and formally request a waiver of regulations Print Name: _______________________________________ Signature: ______________________________________ Date: ____ / _____ / _____ Part Five To be completed by SROAcademic Registry CommentsStudent抯 record has been amended to split Part ____ of their programme across 20___ and 20___ Student is considered to be studying a full time programme on a part-time basis25. FACULTY CONTACT扴 DECLARATION I confirm that the above information is correct and relevant agencies (e.g. SLC) have been informed of changed circumstances. Print Name: _______________________________________ Signature: ______________________________________ Date: ____ / _____ / _____ Once this form has been completed please return to Student Records & Operations to allow the student record to be updated and keep a copy within the department. SRO to send a PDF copy to Simon Wombwell ( HYPERLINK "mailto:s.l.r.wombwell@lboro.hslppt.com" s.l.r.wombwell@lboro.hslppt.com), Performance Sport, Education and Development Manager - once finalised.     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