OLYMPIC SCHOLARSHIPS FOR ATHLETES “RIO 2016”

EVALUATION FORM

National Olympic Committee

Period from 01/05/2016 to 08/31/2016

ATHLETE
Family Name Davis Given Name(s) Wayne
Sport Track and Field Discipline 110 Hurdles
Name of coach Andreas Behm

TRAINING (DESCRIPTION, LOCATION AND DATES)

Track – Paradis Valley Community College, 17402 N 40th St Phoenix AZ Mon to Fri 9 am to 11:30am
Weights – EXOS 2629 E Rose Garden Ln, Phoenix AZ 85050 Wed and Fri 1:30 to 3:30

COMPETITION RESULTS
Dates (dd/mm/yyyy)
Competition Venue Results
From To
6/26 Sagicor Senior Champs HC statium
Trinidad
7/10 Blue Marlins Track Classic Bahamas 13.81

RIO OLYMPIC GAMES QUALIFICATION STATUS

Has the scholarship holder qualified for the Rio Olympic Games?

If yes: Competition Date Venue

Result
If no: Next possibility Date Venue

MEDICAL
Has the athlete suffered any injuries or medical problems? If so, please describe.

Hamstring and groin strain which was healed by trials but since I had limited competition for the season was
unable to make the Rio mark

COMMENTS
Athlete Hamstring and groin strain which was healed by trials but since I had limited competition for
the season was unable to make the Rio mark

Coach Letter from coach included in Jan to April evaluation

Olympic Solidarity – 2013–2016 World Programmes 1

 OLYMPIC SCHOLARSHIPS FOR ATHLETES “RIO 2016”
EVALUATION FORM

FINANCIAL STATEMENT: MONTHLY SCHOLARSHIP DISTRIBUTION

 Please refer to the athlete/NF/NOC contract and complete and sign the financial statement below.
 Statements without the valid signatures of all parties will not be accepted.
 The NOC should keep an accurate account of all financial transactions that have occurred.
 Olympic Solidarity reserves the right to request any additional financial documentation as need be.
Description of Expenditure Direct beneficiary Expenditure Expenditure
Coaching costs, transport, competition costs, etc. Athlete, coach. Local currency Exchange rate:
1 USD = …
Coach Athlete 1000
Housing Athlete 806

Total for month of May ..................... 1806 USD

Coach Athlete 1000
Housing Athlete 806

Total for month of June ................... 1806 USD

Coach Athlete 1000
Housing Athlete 806

Total for month of July ..................... 1806 USD

Coach Athlete 1000
Housing Athlete 806

Total for month of Aug ..................... 1806 USD

GRAND TOTAL 7224 USD

I, the undersigned ATHLETE, acknowledge that I have benefited from the monthly funds of the Olympic scholarship as listed
above and hereby certify that the information in this report is a true and honest representation of the use of the Olympic
scholarship funds.

9/30/2016
Name and signature: Date:

I, the undersigned, on behalf of the National Federation of __________________ hereby certify that the information provided
in this report is a true and honest representation of the use of the Olympic scholarship funds for the athlete concerned.

Stamp
Name, function and signature: Date:

I, the undersigned, President/Secretary General, on behalf of the NOC of ____________________ hereby certify that the
information provided in this report is a true and honest representation of the use of the Olympic scholarship funds for the athlete
concerned and that the NOC takes full responsibility for the financial accuracy of this statement:

Stamp
Name, function (President or Secretary General) and signature: Date:

This form is also available on NOCnet http://extranet.olympic.org/nocnet

Olympic Solidarity – 2013–2016 World Programmes 2