Application for a place on a scholarship course designed to give disabled people the opportunity to enjoy a flying training experience:

Step 1

Name:
Date of Birth:
Address:
Telephone / Mobile:
Email:

Step 2

Create a personal note. Please tell us, in no more than two A4 pages, your personal circumstances and why you wish to be considered for a Suzi Duncan Scholarship. Please include:

a brief description of your disability

your reasons for wishing to take part in this program

whether or not you have flown in a light aircraft before either as a passenger or pilot and before or after your disability occurred (this will not impact your application)

some details on your personal circumstances and your background

Step 3

Scan and attach or print the personal note.

Scan and attach or print a full length photograph of yourself

Scan and attachor print a copy of your driver’s licence

(if you have a driver’s licence go to step 4)

(if you do not have a driver’s licence go to step 3a)

Step 3a

If you do not have a driver’s licence, you are required to obtain a certificate from your doctor stating that you are medically fit to fly under supervision in a flight training experience and are not on any medication that would preventyou from driving a car. (The certificate must be attached to this application)

Step 4

Date and sign the following declaration:

DECLARATION

I understand and agree that my acceptance or otherwisefor the course or a scholarship is completely at the discretion of Wheelies with Wings.

I indemnify and release Wheelies with Wings against all claims and expenses related to my participation in the course.

Wheelies with Wings is not liable to indemnify me against any risk whatsoever including any action which may later be found negligent.

I am personally responsible for all arrangements regarding medical and any other insurance which I consider appropriate in the circumstances.

Prior to undertaking the course I have made or will make professional inquiries regarding the type and levels of insurance which I should obtain.

I understand that Wheelies with Wings is not an insurance expert and is unable to advise me on the adequacy of any insurance.

I agree to accept accommodation at TEMORA while undergoing the course as I understand that part of the aim of the course is to encourage disabled people to develop a spirit of independence, self-reliance and camaraderie.

Signed / Date

Step 5

Scan or Print this form and attachments and send either by snail mail or email, to Wheelies with Wings:

: / Or / Rob Rickards
Wheelies with Wings
P.O. Box 718
Hurstbridge VIC 3099