16-19 Bursary Fund: Student Application Form

16-19 Bursary Fund: Student Application Form

16-19 Bursary Fund: Student Application Form

Applications cannot be made until a Sixth Form place has been confirmed in writing to you and you have commenced your studies as a Post 16 student at Wales High School.

Please note the Important Conditions on page 5 before signing the application.

  1. Student Details

Surname:
First Names:
Date of Birth:
Address:
Post Code
e-mail address
Home Phone / Mobile Phone
  1. Bank or Building Society Details

To receive payments, you must have a bank account in the STUDENTS OWN NAME that will accept BACS payments. If you do not have a bank account, you need to open one before completing this form.

Name of Account Holder
Name of Bank
Branch
Sort Code
Account Number
Roll Number
  1. Course Details

Please indicate if you are studying any of the following subjects:

Tick if studying
BIOLOGY
ENGLISH
GEOGRAPHY
GEOLOGY
HISTORY
PUBLIC SERVICES
  1. Financial Information

Free School Meals

Are/ were you and/or your siblings who live in the same house as you in receipt of free school meals? Yes No

Brother/Sister’s Name …………………………………

Adult Household Members

Person 1 / Person 2
Surname
Forename
Relationship to Student
Telephone

Financial Assessment – Income

To be completed by the person(s) responsible for the household bills

Person 1 / Are you employed/ Self -employed
Yes No / If yes please submit P60 or for Self -employed SA302 or certified accounts for last accounting period, plus child tax credit award notice dated 2013-14
Person 2 / Are you employed/ Self – employed
Yes No / If yes please submit P60 or for Self -employed SA302 or certified accounts for last accounting period, plus child tax credit award notice dated 2013-14

All applicants MUST provide the following documentation with this application

Document / Tick if included
Copy of entitlement/ award letter to means tested state benefit (i.e. housing benefit, income support, incapacity benefit) –This must be dated within the last three months
Child Tax credit award notice marked “2013-14”
  1. Declaration

Please read the following declaration carefully before signing.

I declare that the statements made on this form are true and to the best of my knowledge and belief are correct in every respect. I will supply any additional information that may be required to verify the information given. I understand that if I refuse to provide information relevant to my claim the application will not be accepted. I will also inform Wales High School of any alteration to any of the declarations in writing. I agree to repay Wales High School in full and immediately any monies awarded to me if the information I have given is shown to be false or deliberately misleading. I am aware that the funding covers only this academic year and that I must re-apply next year. I also understand that there is no guarantee that I will receive funding for future years even if I qualify for the current year.

STUDENT / PERSON 1 or 2
Signed
Print Name
Date

For Office Use Only

Is this application Supported ? Yes No

Financial Assessment and Eligibility confirmed? Yes No

Bursary Awarded: Course Trips:

HIGH (£1,200) *
MEDIUM (£400)
LOW (£250)
OTHER (Emergency)
BIOLOGY
ENGLISH
GEOGRAPHY
GEOLOGY
HISTORY
PUBLIC SERVICES

TOTAL AMOUNT AWARDED ……………………….

Signed (Director of Sixth Form)………………………… Date ……………………..

*If eligible for the £1,200 bursary complete the EFA Funding Claim Form

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