2016Rod Kershaw ASM Scholarship

Paramedics Australasia South Australia

SA Ambulance Service

The Quest for Excellence

USE THIS FORM ONLY – DO NOT USE ADDITIONAL PAGES OR SUPPORTING DOCUMENTS. USE BLACK PEN or BLACK TYPE ONLY. PLEASE USE BLOCK LETTERS ONLY. SUBMIT ONE ORIGINAL AND ONE PHOTOCOPY OF YOUR APPLICATION.

PERSONAL DETAILS & HISTORY

1. Please complete the below personal details
Title / Given Names / Surname
Home Address / Post Code
Postal Address / Post Code
Telephone / Work / Home / Mobile
Email / Date Of Birth
PA Member Number / Length Of Membership (YY/MM)
2. Have you previously been awarded the Rod Kershaw ASM scholarship or the PA SA pre-hospital scholarship?
YES / NO / If YES, what year was this awarded?
3. Please provide a list below of all previous awards, prizes or grants that you have achieved
Name of Grant or Award / Year Achieved

EDUCATION HISTORY

4. Please provide a list below of all your formal post-secondary educational qualifications and achievements.
Educational Qualification / Institution / Year Completed

EMPLOYMENT HISTORY

5. Please provide an overview of your employment history.
Position Held / Employer / Period Employed

REASON FOR APPLICATION

6. In no more than 250 words, please describe below the reason/s for your application.

KEY AIMS AND OUTCOMES

7. Please list below the key aims and/or outcomes you wish to achieve from undertaking the Rod Kershaw ASM Scholarship.

PROCESS TO ACHIEVE AIMS/OUTCOMES

8. In detail below, please describe how you intend to achieve the aims/outcomes identified above. This should include references to key contact organisations, individuals, destination country/ies, visits, conference details etc.
9. What expertise do you have that will assist you to undertake this research?

REASONS FOR APPLICATION

10. What benefit will be gained by traveling to your chosen destination to undertake this research, as apposed to carrying out your research from South Australia?
11. Explain in detail, how your research will benefit PA SA, SA Ambulance Service and the field of paramedicine.

PROPOSED ITINERARY

12. Please provide an overview below of your intended daily travel itinerary as part of the Rod Kershaw ASM Scholarship for up to 28 Days.
Day / Date / Destination / Proposed Itinerary / Accommodation Arrangements / Travel Arrangements / Miscellaneous Arrangements
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Day 11
Day 12
Day 13
Day 14
Day / Date / Destination / Proposed Itinerary / Accommodation Arrangements / Travel Arrangements / Miscellaneous Arrangements
Day 15
Day 16
Day 17
Day 18
Day 19
Day 20
Day 21
Day 22
Day 23
Day 24
Day 25
Day 26
Day 27
Day 28

ESTIMATION OF SCHOLARSHIP EXPENSES

13. Provide an estimation or quote below of your intended daily travel costs as part of the Rod Kershaw ASM Scholarship. All figures below should ideally be quoted in Australian Dollars, where this is not possible please ensure that you indicate currency type and exchange rate. Exchange rate is the rate at time of application.
Day / Exchange Rate / Airfare
Costs / Local Transport Costs & Transfers / Accommodation Costs / Meal
Costs / Miscellaneous Costs (please specify each)
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Day 8
Day 9
Day 10
Day 11
Day 12
Day 13
Day 14
Sub Total
Day / Exchange Rate / Airfare
Costs / Local Transport Costs & Transfers / Accommodation Costs / Meal
Costs / Miscellaneous Costs (please specify each)
Day 15
Day 16
Day 17
Day 18
Day 19
Day 20
Day 21
Day 22
Day 23
Day 24
Day 25
Day 26
Day 27
Day 28
Sub Total
Total
14. If successful in being awarded the Rod Kershaw ASM Scholarship, I am willing to pay a refundable* bond of AUD $1000.00 within 7 days of signing the scholarship contract. This refundable bond must be received by PA SA before any travel arrangements or payments towards costs will be authorised by PA SA.
(*Refundable once all contractual obligations of the scholarship have been met to the satisfaction of PA SA and SA Ambulance Service)
YES / NO
15. I have read and understood the Rod Kershaw ASM Scholarship Contract.
YES / NO
16. I have attached the two required references.
YES / NO
17. I have attached an accurate (as possible) expense report.
YES / NO
18. Signed / Date
POST TO: PA SA, Rod Kershaw ASM Scholarship, C/-. PO Box 647
Modbury SA 5092
APPLICATIONS MUST REACH PA(SA) BY COBFriday 13MAR15

2015 Rod Kershaw ASM Scholarship

Paramedics Australasia South Australia

& SA Ambulance Service

The Quest for Excellence

REFEREE REPORT

Please complete Referee details.

Title:……… Given Names:………………………………Surname ………….………………………………

Address:………………………………………………………………………………………….

Postcode:………...

Telephone: (Work) ……………………. (Home) …………………….. (Mobile) ………………………

Please complete Applicants details:

Title:…………Given Name ………………………………Surname……………………………………..

How long have you know the applicant?......

Please describe the qualities and attributes this applicant has which would assist them to achieve

the goals as outlined on their Rod Kershaw ASM Scholarship application.

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Why do you think this applicant would be a good representative of PA SA and SA Ambulance Service?

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Any other comments – communication skills, presentation skills, personality etc

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Signed ………………………………………………………………..Date…………………………..