Access DCU Supports Application Form

Dublin City University Ollscoil Chathair Bhaile Átha Cliath

Access DCU Supports Application Form

Closing date: April 26, 2013

Access DCU Supports – Application form for entry Autumn 2013. Closing date: April 26, 2013.

1) Your Personal Details

2) Your Address & Contact Details

Name:

House Name:

Surname:

House Number:

Date of Birth:

Address 1:

Country of Birth:

Address 2:

Nationality:

Address 3:

PPS Number:

Area/Town:

CAO Number:

Postcode: c Male c Female

Gender

County:

School Name:

Email address:

School County:

Your Mobile No:

3) Your Family’s Dependents First Name

Date

Certified unfit

School/College

Full

Part

Highest Level

of Birth

for work*

Attending

time

time

of Education

c Yes c No

c FT c PT

c Yes c No

c FT c PT

c Yes c No

c FT c PT

c Yes c No

c FT c PT

c Yes c No

c FT c PT

c Yes c No

c FT c PT

*Please see guide.

4) Your Parent(s)/Guardian(s) Currently in Education College/University Attending

Course Type

College/University Attending

Course Type

Mother

c FT c PT

Guardian 1

c FT c PT

Father

c FT c PT

Guardian 2

c FT c PT

5) Your Family Status My parents are married and/or live together

c

My parents are separated/divorced

c

I live in a single parent household with NO financial contribution from the other parent

c

I live in a single parent household with SOME financial contribution from the other parent

c

My parent is a widow/widower

c

I have legal guardians who are not my parents

c

I am in the care of the Health Service Executive

c

I am a separated child

c

I am a foster child

c

I am a member of the Traveller Community

c

6A) Your Parent(s)/Guardian(s) Employment Status Father

Mother

Guardian 1

Guardian 2

Spouse

Working for payment/profit – Full Time

c

c

c

c

c

Working for payment/profit – Part Time

c

c

c

c

c

Unemployed

c

c

c

c

c

Looking after the home / family

c

c

c

c

c

Retired from employment

c

c

c

c

c

No contact whatsoever

c

c

c

c

c

Never worked

c

c

c

c

c

Unable to work due to permanent sickness/disability

c

c

c

c

c

Deceased

c

c

c

c

c

Other, Explain: ____________________________

c

c

c

c

c

6B) Your Parent(s)/Guardian(s) Job Title and Type of Employment Job Title

Employee

Self-Employed

Self-Employed (including farmer)

(including farmer)

with paid employees

Mother

c

c

c

Father

c

c

c

Guardian 1

c

c

c

Guardian 2

c

c

c

Spouse

c

c

c

7) Your Family Financial Circumstances

Was your Parent/Guardian/Spouse working

Mother

Father

Guardian 1

Guardian 2

Spouse

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

c

as an employee in 2011? Did he/she receive payments from sources like PAYE, salary, fees, wages, FAS or a CE scheme?

Was your Parent/Guardian/Spouse self-employed in 2011? Did he/she receive income from self-employment?

Did your Parent/Guardian/Spouse receive any income in 2011 from land, such as income from farming or renting property?

Did your Parent/Guardian/Spouse receive income in 2011 from the Department of Social and Family Affairs such as social assistance or social insurance payments?

Did your Parent/Guardian/Spouse receive income from any other sources in 2011 such as maintenance payment or child support?

Was your Parent/Guardian/Spouse made redundant in 2011? Did he/she receive any lump sum payments from his/her employer?

8) Your Family Medical Card/GP Visit Card Do you or your Parent(s)/Guardians(s)/Spouse have a Medical Card / GP Visit Card valid on 31st December 2012?

c Yes

c No

9) Your additional details (100-300 words)

10) Your access support Options I would like to be considered for the Subsidised Accomodation & Access Supports

c Yes

I would like to be considered for the Reduced point entry with financial scholarship and Access supports

c Yes

11) Your Declaration c Yes

I certify that the information supplied in this application form is correct and complete.

I agree that my financial details and supporting documents may be reviewed by an independent financial advisor and they will be treated confidentially.

c Yes

I understand that some details of my application will be used for research purposes but my name will never be used.

c Yes

I understand that if I have misrepresented myself or give false declaration I will be ineligible for this Scholarship.

c Yes

Applicant Signature

Date

Send your Application Form and all supporting financial documents to DCU Access Service, Henry Grattan Building, Dublin City University, Dublin 9 by April 26, 2013.

Applications and supporting financial documents received after April 26, 2013, will NOT be considered.

Apply for your supporting financial documents early as they can take time to gather.

Keep a photocopy and proof of postage of all documents submitted.

For information on other grants/financial assistance available for students log on to www.studentfinance.ie

Request for Information from the Department of Social Protection Part 1: To be completed by Applicant's Parent(s)/Guardian(s)/Spouse I authorise the release of information outlined below for the purpose of assessing a DCU Access Supports Application.

Mother/Guardian/Spouse’s Signature

Father/Guardian/Spouse’s Signature

Part 2: To be completed by your Local Social Welfare Office DCU Access Service run a scheme for students from socio-economically disadvantaged backgrounds.

School leavers who present satisfactory evidence relating to their socio-economic circumstances and satisfy academic requirements are eligible to compete for a quota of places allocated on a reduced leaving certificate points/subsidised accomodation basis.

To faciliate applicants in submitting required evidence, the Department of Social Protection (DSP) is requested to provide TWO pieces of information in respect of the person(s) named above: 1. Was the parent/guardian spouse in receipt of a means-tested (social assistance) payment(s) for at least 26 weeks in 2011?

2. What was the total (excluding child benefit, early childcare supplement and supplements paid under SWA scheme) social welfare income received by the parent(s)/guardian(s)/spouse in 2011?

Please do not change any dates on this form. The assessment year is 2011.

Applicants must submit this information in relation to BOTH parents/guardians where applicable.

Please be advised that this form cannot be accepted unless it is both signed and stamped by a DSP official. Failure to submit appropriately verified information will result in the applicant being ineligible.

Mother/Guardian/Spouse Name: PPS Number: In receipt of means-tested social assistance for at least 26 weeks in 2011?

YES

NO

YES

NO

Total Social Welfare Income* paid to this PPS number in 2011? €

Father/Guardian/Spouse Name: PPS Number: In receipt of means-tested social assistance for at least 26 weeks in 2011?

Total Social Welfare Income* paid to this PPS number in 2011? €

*Child Benefit, Early Childcare Supplement & any Supplements paid under the Supplementary Welfare Allowance Scheme should be excluded from the total income figure.

DSP Official Stamp

Signed on behalf of DSP (please print your name)

What is your position in DSP?

Form not valid unless stamped Signature

Date

Part 3: To be completed by Applicant Applicant's Name: Applicant's CAO Number: Applicant's Date of Birth:

/

/19

Applicant's PPS Number:

Keep photocopy and proof of postage. Submit all documents by 26 April 2013 to DCU Access Service, Henry Grattan Building, Dublin City University, Dublin 9.

Request for Information from the Health Service Executive Part 1: To be completed by Applicant Applicant's Name: Applicant's CAO Number: Applicant's Date of Birth:

/

/19

Applicant's PPS Number:

You can find details of all HSE Local Health Offices on the website www.hse.ie or LoCall 1850 24 1850

Part 2: To be completed by the Health Service Executive DCU Access Service run an admissions scheme for students from socio-economically disadvantaged backgrounds. School leavers who present satisfactory evidence relating to their socio-economic circumstances and satisfy academic requirements are eligible to compete for a quota of places allocated on a reduced leaving certificate points/subsidised accomodation basis To faciliate applicants in submitting required evidence, the Health Service Executive is requested to provide the following information in respect of the person named above:

Does the applicant hold or are they dependant on a parent/guardian/spouse who holds a Medical Card or GP Visit Card valid on 31 December 2012?

YES

NO

I certify that the above applicant holds or is dependant on a parent/guardian/spouse who holds a Medical Card/GP Visit Card that is valid on 31 December 2012.

Signed on behalf of HSE (please print your name)

HSE Official Stamp

What is your position in HSE? Form not valid unless stamped Signature

Date

Applicants must submit this evidence to DCU Access Service by 26 April 2013.

Out of date or pending Medical Cards/GP Visit Cards will not be considered.

Please be advised that the certification cannot be accepted unless it is both signed and stamped by a HSE official. General Practitioner Stamps will not be accepted. Failure to submit appropriately verified information will result in the applicant being ineligible.