Scholarship Form

Section A: Applicant Details

Who is the applicant?

First Name *

Last Name *

Mobile *

Email Address *

Gender

MaleFemale

Age

Are you a parent or carer? If you are completing this application on behalf of another person (the applicant) please provide the following details:

Parent / Carer First Name

Parent / Carer Last Name

Parent / Carer Mobile

Parent / Carer Email address

Section B: Eligibility

Do you live in a property managed by the WHC?

YesNo

Are you up to date with all your rent and utility payments?

YesNo

How much funding are you seeking from the scholarship?

Primary School - up to $500High School - up to $1,000Tertiary Education or Professional Development - up to $2,000

Please detail all costs below. List items in relation to application. Eg, course details and cost

Item 1

Estimated cost (GST inclusive) 1

Item 2

Estimated cost (GST inclusive) 2

Item 3

Estimated cost (GST inclusive) 3

Item 4

Estimated cost (GST inclusive) 4

Total cost

Please provide details of the name of the school, university, college, TAFE or sporting/music program that the individual will be enrolled in and the contact details for that organisation.

Name of institution

Name of course and year of study

Telephone number

Email address of organization

Section C: Assessment Criteria

1. Please describe why you would like to undertake the course and/or activity and the difference it will make to you/the applicant.

2. Please describe how the scholarship will assist you or the applicant to complete the course and/or activity

3. If you are awarded a scholarship, are you able to provide a brief written report that describes how the scholarship was used and the difference it made to undertaking the course and/or activity?

YesNo

Section D: Declaration

I certify that the information supplied in this application is correct and that I give the Women’s Housing Company permission to use the information that is contained in this application form to assess the merit of my application. *

I confirm that the information I have provided is true and accurate, and understand that any scholarship offer may be withdrawn if selection is made on the basis of false or misleading information. *

I agree to the Women’s Housing Company contacting me to discuss how the scholarship contributed to achieving my goals and reaching my full potential. *

I agree to provide evidence of quotes and charges in order to receive payment of any funds that are awarded to me and submit evidence of successful completion. *