Student Details

Title: / Forename(s): / Surname:
Address:
Postcode:
Tel No: / Date of Birth: / Age on 31 /08/2017: / ECHP: Y / N

Vulnerable Bursary

Do you qualify under any of the following priority groups?
Are you in Care?
Are you a Care Leaver?
Are you in receipt of Income Support?
Or Universal Credit in place of Income Support?
Are you in receipt of ESA and DLA
Or ESA and Personal Independence Payments? / Please provide confirmation of your current looked-after status from the local authority that looks after you.

Please provide confirmation of your previous looked-after status from the local authority which provides your leaving care service.

Please provide evidence of this from Jobcentre Plus which confirms that you can be in further education or training.

Please provide evidence of this from Jobcentre Plus which confirms that you can be in further education or training.
Discretionary Bursary
Do you, your parent(s) or guardian(s) receive any of the following benefits?

Universal Credit?

Job Seekers Allowance?

Income Support?

Council Tax Benefit?

Employment and Support Allowance?

Housing Benefit?

Or have a household income below £22,000
OTHER
I do not meet any of the above criteria but still need financial support to help with travel.
Please Tick:
Bank Account Details:
If your application is successful, in most cases payments will be made directly into your bank account
Please provide the following details:
Bank name:
Account name:
Sort code:
Account number:
Declaration
I agree that all funds received are on the understanding that I regularly attend St Helens Chamber and make good progress on my course. I will inform my tutor if my financial circumstances change. I understand that I may be required to repay all or part of the award if I leave St Helens Chamber prior to the completion of the course. I certify that the above information is correctand I recognise that false statements can leave me open to prosecution.
I am not in receipt of financial support for any of the items above from any other source (e.g. Job Centre Plus)
In order to receive this support I understand that I must meet the standards for behaviour and attendance set out in thebehaviour protocol.
I agree that St Helens Chamber can process my personal data contained on this form in order to assess my eligibility for bursary support.
Student Signature: ______
Name:______Date:______

V7.0Last amended: 01/08/2017

For Office Use

Unique Learning Number: ______Learner Ref Number: ______
Application Received Date: / Staff Signature:
Proof of benefit entitlement provided: / YES / NO / Date:

Student meets all other general eligibility criteria: YES / NO

Panel Decision:

Application: Approved / Rejected / Further Information Requested

Allocation:

Vulnerable  Discretionary 

Bursary Type: Full / Prorata: Course Length:

Weekly payment
(vulnerable): / £ / Total Amount required (vulnerable): / £
Recycled funds (vulnerable) / £ / Net amount applied for (vulnerable): / £

Travel Pass

Decision made by:

Signature ______Position ______Date ______

Approved bursary has been entered on the learners PICS record(Please tick)

Notes & Dates:

Date / Comments / By Whom

Work Ready – Chamber Approved

Financial Support Log

Name –

Funding Source: EFA  OperatingCost  Vulnerable 

Travel Bursary

Week / Pass No / Date / Learner Signature / Issued by
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Vulnerable Bursary (If bank account not available)

Week / Amount / Date / Learner Signature / Issued by
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2
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Additional Bursary (clothing, PPE, emergencies)

Reason / Amount / Date / Learner Signature / Issued by

V7.0Last amended: 01/08/2017