BURSARY FUND APPLICATION FORM 2013-‐14
Please note the following important information:
• • •
You should read the Bursary Fund Guidelines 2013-‐14 available on our website www.lapwingsuffolk.org.uk to make sure you are eligible to apply (if you do not have access to the Internet please contact our finance team on 01473 604809). Please complete all sections of the form and make sure you provide us with copies of the evidence we need. Your application will not be assessed without the correct evidence. The budget we have available is limited so we cannot guarantee that we will be able to provide you with financial support throughout the entire academic year, although we will do our best to do so. Payments of all bursaries are dependent on you maintaining attendance of 80% or above and behaving appropriately during your Lapwing programme.
When you have completed this form please return it, fully completed with evidence to the Head of Finance at Lapwing Suffolk, IP-‐City Centre, 1 Bath Street, Ipswich, IP2 8SD.
SECTION 1 : PERSONAL DETAILS Full Name :
Gender : Male Female
Date of Birth : Age at 31/08/13:
Your current address :
Your parent(s) / guardian(s) name(s) and address(es) if different :
Telephone Number(s) :
SECTION 2 : RESIDENCY
Please select which of the following applies to you : British Citizen EU / EEA Citizen
Asylum Seeker Refugee Indefinite Leave to Remain Other (please specify)
Have you been resident in the UK or EU/EEA for the last 3 years? Yes No
SECTION 3 : COURSE DETAILS
Your Lapwing start date :
Your Lapwing end date:
SECTION 4 : GUARANTEED BURSARY (for students living in care, have left care, on income support or universal credit in own right, or receiving Employment Support Allowance & Disability Living Allowance or Personal Independence Payment in own right) Are you (the student) aged 16 or over and under 19 at the start of the academic year (31 August 2013): Yes Please continue with Section 3 No You will not be eligible for the guaranteed bursary but please continue to Section 5
Are you (the student) : Please only tick a box if you are answering “yes” In Care A Care Leaver In receipt of Income Support or Universal Credit In receipt of Employment Support Allowance and Disability Living Allowance or Personal Independence Payment
If you have ticked any of the boxes above please go straight to Section 6 of this application. If the above does not apply to you please continue to Section 5.
SECTION 5 : DISCRETIONARY BURSARY (you only have to provide evidence for one of the target groups but please answer all questions) Are you (the student) aged 16 or over and under 24 at the start of the academic year (31 August 2013): Yes Please continue with Section 5 No You will not be eligible for the discretionary bursary funding
Target Group 1
Did you receive free school meals in 2012/13 : Yes No
Target Group 2
Are your parent(s)/guardian(s), in receipt of one or more of the following benefits : Please tick all that apply Income Support Income-‐based Job Seeker’s Allowance Child Tax Credit (with gross annual income of less than £16,190) Income-‐based Employment and Support Allowance Guaranteed Element of State Pension Credit
Do you fall into one of the above groups? Yes No If you do not fall into one of the above groups we will need to assess your needs once we have received your application. You may not therefore be automatically eligible for funding.
SECTION 6 : STUDENT & PARENT/GUARDIAN DECLARATION
This declaration must be signed by all students or parents/guardians. If the income evidence provided belongs to parent(s)/guardian(s) then we must also have a parent/guardian signature. I/we certify that the information given is, to the best of my/our knowledge and belief correct. I/we understand that payments may be delayed or stopped if I do not maintain at least 80% attendance. I/we undertake to inform Lapwing immediately, if I, the applicant, decide to leave my programme. I/we understand that it may be necessary for Lapwing to use information given, or share the information provided, to prevent and detect fraud.
Student’s Signature ………………………………………………………………….. Date : / /
Parent/Guardian’s Signature ………………….………………………………… Date : / /