Deadline to apply: Friday 27 October 2017
NB Please read the guidance notes BEFORE completing this application form
1. Personal detailsStudent ID: / Date of Birth: (dd/mm/yy)
Title:
(Mr/Mrs/Miss/Ms)
First Name(s): / Surname:
HOME ADDRESS
House No./Road/Street: / Town:
County: / Postcode:
TERM TIME ADDRESS
House No./Road/Street: / Town:
County: / Postcode:
CU Email: / Home email:
Mobile number:
2. POLAR Group (postcode)
Please which group your post code is in (see guidance notes) / 1 2
3. Higher Education
Are you the first in your immediate family to go to university? / Yes No
4. Household Income
What is the household incomefor your home address?
(this must be £30,000 or below for you to be eligible for a scholarship and we will need proof of income) / £
Are you from a single parent household? / Yes No
If yes please provide evidence to show this e.g. Tax Credit Award Notice, Council Tax Bill etc.
5. Course Details
Course title:
Year of Study: 1 2 3 4 / Placement Year: Yes No
For 2nd, 3rd and 4th years, please state your overall grade for the previous year.
Reasons for applying
The aim of the National Express Foundation programme is to support students with challenging personal and financial circumstances and in doing so enable them to advance their further and higher education. Please bear this in mind when answering the following questions.
6. Why are you applying for a National Express scholarship? Tell us about your particular needs and circumstances7. How do you intend to use the money if you are successful? Please be as specific as possible i.e. do you need equipment, money for travel, funding for extra resources etc?
8. What are your goals for the next year and how will this scholarship help you to achieve them?
Another aim of the National Express Foundation is to provide grants to charitable and communitygroups for projects which support children and young people and promote cross-community cohesion and understanding
9. Have you ever done any charitable/volunteering work in your local area?Yes No
If yes, please name the charity or voluntary group and describe what you did and the people you worked with
or helped?
10. Scholarships
I can confirm that I am NOT in receipt of any other scholarships Yes
Signature………………………………………………………………………….Date………………………………......
EQUAL OPPORTUNITIES MONITORING FORMPlease answer all 5 questions putting a in the relevant boxes
- Gender
Male
Female
Transgender
- Age
Under 21
Over 21
- Disability
I have a disability
I do not have a disability
I prefer not to say
If you said you have a disability, please choose from the categories below.
Physical
Sensory (sight, hearing)
Learning (dyslexia)
Mental health
Other (please state)
- Ethnicity
White
Black
South Asian
Chinese
Mixed
Other Asian
Other
Prefer not to say
- Access to information
How did you find out about the National Express scholarships?
Student CentreUniversity student portal
CU Facebookdirect email
Website Other (please state)
Please email completed form to Friday 27 October
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