3. Supporting Financial Documentation (As Listed Below) Must Be Submitted with Your Application

REACH
School Leavers Access Programme
2009/10 /

1.  The first step is to complete this application form and gather the financial documentation (see 3 below). The completed form should be submitted to either your School Principal or Guidance Counsellor.

2.  Your School Principal, Year Head, Form Teacher or Guidance Counsellor is also required to submit a reference to support your application (see page 9). The reference must be submitted by your School
together with the completed application form and supporting financial documentation.

3.  Supporting financial documentation (as listed below) must be submitted with your application form

4.  PAYE Employee, Self-employed and Persons engaged in Farming Activities:

i.  A P21 for year ended 31 December 2008 must be provided for your household. A P21 is a statement of total income, tax credits and tax paid which is issued from your District Tax Office (before sending it with this application, you should take a copy as you will need it for any college grant applications you make).

5.  Social Welfare Recipient

i.  Where a Parent(s) or Guardian(s) are in receipt of a payment from the Department of Social, Community and Family Affairs a statement from your local Social Welfare Office showing the total amounts received for the year ended 31 December 2008

ii.  OR

iii.  Your local Social Welfare Office must stamp Page 8 of the REACH application form (Section C) indicating your current weekly payment and the nature of the payment.

b.  Any other financial documentation which will assist your eligibility for the programme.

6.  The closing date for receipt of applications is Monday Thursday 12th March 2009. Applications forms should be submitted by your School to the Access Office, Institute of Technology Blanchardstown, Blanchardstown Road North, Dublin 15.

7.  Your application form and supporting documentation will be used as the basis of assessing eligibility for the programme. (Please note that applicants cannot be considered if supporting documentation is not submitted with the application).

8.  Information sessions in respect of this programme may also be held, at which attendance by applicants is advised.

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REACH 2009/10

School Leavers Access Programme

Institute of Technology Blanchardstown

Completed applications must be returned by your School/College

to the Access Office, ITB not later than Thursday 12th March 2009

Name:
(as on Birth Cert) / Date of Birth:

Country of Birth:

/ /

Home Phone No:

/

Email Address:

/ /

Mobile Phone No:

/
Address:

Course Choices

Please list the course codes for the ITB courses for which you are applying under the REACH Programme in order

of preference (e.g. BN001). These courses must also be listed on your CAO application form.

Level 6 / 7 / Level 8
1 / 1
2 / 2
3 / 3
4 / 4

PPS Number: 2008CAO Number: (8 digit number)

0 / 9

Second Level Attendance

Schools Attended / Date of attendance
From: To:

Second Level Examinations

Junior

Certificate /

Leaving Certificate

Subjects 2009 /

Leaving Certificate

(prior to 2009*
Year of Examination / Year of Examination
Subjects / Level H or Ord / Grade or Mark / Subjects / Level
H or Ord / Subjects Level
/ Grade or Mark
* Please attach a copy of these results

Post Secondary Education (If applicable) e.g. Post Leaving Certificate courses

College Attended /

Dates of Attendance

From To /

Course Title

(Include list of modules taken) /

Qualifications Attained

(List results achieved in each module e.g. Pass, Merit, Distinction)

Involvement in other activities in preparation for Third level

Give details of any involvement that you have had with this Institute or any other third-level college initiative, e.g. TASTER Programme, Shadowing events, Summer School, Tutoring Programme, Supervised study, open days, Higher options exhibitions etc.

REACH

School Leavers Access Programme

Institute of Technology Blanchardstown

Applicant’s Supplementary Information Statement

Name of Student: ______

Please answer all the questions below. You do not need to use all the space available – however, if the space provided is inadequate, you may use a maximum of one additional page.

Please ensure that your answers are legible.

1.  The reasons why you wish to go to the Institute of Technology Blanchardstown.

______

______

______

2. Your reasons for choosing the course(s) listed in your application form: (please make reference to

course content, what you know of the course from your research)

______

______

______

______

3. Your goal on completion of the course (career sought).

______

______

______

4.  The reason you think you should be offered a place under the REACH programme.

______

______

______

______

5.  What was your least favourite subject at school and how did you deal with this subject? Were
you successful in this subject in your exams to date?

______

______

______

______

6.  Your personal strengths and experiences which you believe will help you to enjoy and succeed in your chosen course in the Institute.

______

______

______

______

7.  The support and assistance that you think you may need while studying at the Institute.

______

______

______

8.  Details of any employment, work experience, placement, or voluntary work; especially if it is relevant to your choice of course.

______

______

______

9. Your social, sporting or other interests and activities.

______

______

______

______

10.  Any further information which would support this application.

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Applicant’s Signature: ______

Date: ______

REACH

School Leavers Access Programme

Institute of Technology Blanchardstown

(To be completed by parent(s) or guardian(s))

This information will be used for the purposes of selection of students for the School Leavers Access Programme. Under no circumstances will it be disclosed to any other agency or body.

Name of Student: ______

Section A: Particulars of Family (including those currently residing outside family home)

Names of Family members / Date of Birth / Relationship to applicant / *Highest Level of Education achieved to date / Current/Most recent occupation or current place of study

* What is the highest level of education completed by family members? E.g. Primary education, Group/ Inter /Junior Certificate, Leaving Certificate, Post Leaving Certificate, Vocational Training, Adult Education, Higher Certificate, Ordinary Bachelor Degree, Honours Bachelor Degree, Masters programmes, etc

Section B: Confirmation of income

This information is available on parent(s)/guardian(s) P21 which must accompany the application.

If neither parent/guardian is in paid employment, please go to Section C

Total income for the year ended 31 December 2006
Father / Mother / Guardian
Occupation
Basic pay (excluding overtime etc) if different from amount quoted on P21
Income from any other source, please specify:

Section C: Particulars of income (To Be Completed by Social Welfare Only)

This portion of the form must be stamped by your local Social Welfare Office to confirm nature/ level of payment.

Total income for the year ended 31 December 2008
Father / Mother / Guardian
Unemployment Benefit
One Parent Family Payment
State Pension (Non-Contributory)
Job Seekers Allowance
Pre-Retirement Allowance
Farm Assist
Prisoner’s Wife’s Allowance
Part-Time Job Incentive Scheme
Guardian’s Payment (Non-Contributory)
Deserted Wife’s Allowance
Back to Work Allowance Employee
Back to Education Allowance
Supplementary Welfare Allowance
Family Income Supplement
Disability Allowance
Blind Person
Widow/er’s (Non-contributory) Pension
State Pension (Non-Contributory)
Carer’s Allowance
Other : ______
Total Amount received for Year Ending 31/12/2008
Is the applicant covered by a medical card? / No: Yes:
If Yes Provide No: ______
Signed for DSFA: / (Signature & Date)
______/ DSFA Official Stamp
Position in Organisation:
______/ Telephone Number:
______

Declaration

1.  I certify that the information supplied is correct and complete.

2.  I agree that ITB may check my CAO course choices and CAO Change of Mind in order to process my application.

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

4.  I understand that if I have misrepresented myself or given false declaration I will be ineligible for the REACH Programme.

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

Signature of Parent/Guardian: ______Date: ______

Signature of Applicant: ______Date: ______

REACH

School Leavers Access Programme

Institute of Technology Blanchardstown

Academic Reference

Student name: ______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

______

Signature: ______Date: ______

Position: ______

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