Freemasons Foundation Centre for Men S Health

Freemasons Foundation Centre for Men’s Health

Honours Scholarship 2018

APPLICATION FORM

Honours scholarships (competitive) are available to students at the University of Adelaide or other Universities and Research Organisations who wish to undertake an Honours research program in the field of men’s health and who are to be supervised by a registered and actively participating member of the Freemasons Foundation Centre for Men’s Health.

I would like to also be considered for the Paddy O’Rourke Honours Scholarship for prostate cancer research
Yes No
1. Personal Details
Title: / Family Name: / Given Names:
Permanent Home Address:
State: / Post Code:
Home Phone Number:
Semester Postal Address:
State: / Post Code:
Semester Phone Number: / Mobile Number:
Email Address:
What is your date of birth? ……………./…………/……….. Gender : M F
Your undergraduate University: ______
Your University Student Number: ______
Are you: An Australian citizen
An Australian Permanent Resident
Other (see below)
If you are not an Australian Citizen or permanent resident of Australia, do you have a current visa that extends to the end of 2018? Yes No
2. Undergraduate Study Details
Which undergraduate program of study did you undertake? (e.g. Bachelor of Arts)
What year did you finish your undergraduate degree
Have you applied for, or received, any other Honours scholarships? Yes No
If yes, please provide details (including source and amount):
4. Supervisor(s), Collaborator(s) and Project Details (to be completed by applicant & supervisor)
Area/Discipline/ School/Organisation coordinating your project
Name(s) of supervising academic staff member(s) /
If you will be collaborating with other research groups, please provide Researcher name and organisation / N/A
Supervising academics are i) registered and ii) active members of the Freemasons Foundation Centre for Men’s Health / Yes No
Honours Project title
Overview of the project area and outline of the project details (Background, aims, proposed methodology, significance/potential impact)
Note: The Centre recognises that the details of the project may only be very broad at the time of submitting the scholarship application.
Name of Supervisor (please print)
Position Held
Supervisor’s(s) Signature(s) / ……………………………………………………………….. Date…………………..
5. Declaration (to be completed by applicant)
I declare that the information I have supplied on this form is true and correct to the best of my knowledge.
I understand that if I am awarded the scholarship and the Centre at any time thereafter forms the reasonable view that my application included false or misleading information or documentation, the scholarship may be cancelled by the Freemasons Foundation Centre for Men’s Health and any funds I have been paid must be refunded.
I authorise the Freemasons Foundation Centre for Men’s Health to obtain such additional information deemed necessary to assess my application for this scholarship.
I understand that the Freemasons Foundation Centre for Men’s Health, University of Adelaide will not disclose any information supplied on the application form or obtained for the selection process without written consent of the applicant.
I understand that if I am awarded a Freemasons Foundation Centre for Men’s Health Scholarship that I am automatically registered as a student member of the Freemasons Foundation Centre for Men’s Health.
I declare that I will notify the Scholarships office in the event that I accept another scholarship and that by this acceptance I am no longer eligible for a Freemasons Foundation Centre for Men’s Health Scholarship
Applicant signature: Date:

If you have any questions about your application, please contact the Freemasons Foundation Centre for Men’s Health on (08) 8313 0514 or email:

Please forward the completed application form and your CV to:

Freemasons Foundation Centre for Men’s Health, University of Adelaide, Ground Floor, Freemasons Hall, 254 North Terrace, Adelaide, SA 5005