The Blandford School Application Form for Student Support Award

Years 7 - 11 Only

If you wish to apply for a Student Support Award, please complete this form and return it to Ruth Disbrow, Guidance & Welfare Admin Officer.

Alternatively, email the form to: , FAO Ruth Disbrow

SECTION 1a: Student’s Details
Surname / D.O.B
Forename(s) / Age
Address
Post Code
SECTION 1b: Parent/Carer Details
Surname / Forename(s)
Address
Post Code
SECTION 2: Additional information –Family Background.
Please tick and enclose proof, if you are in receipt of any of the following:
Income Support
Child Tax Credit
Working Tax Credit
Job Seekers Allowance (JSA) / Pension Guarantee Credit
Employment and Support Allowance
Support under Part IV of the Immigration and Asylum Act 1999
Was your annual household income in the last tax year (including benefits) below £20,000? / YES NO
Is the student a Young Carer / YES/NO / Do you or the student have a severe disability and receive both ESA and DLA (please provide proof) / YES/NO
Does the student have young children? / YES/NO
Please provide any other information you feel relevant to your application:
SECTION 3: Type of Assistance Requested
Documentary evidence of these costs must be provided unless the cost is a charge made by the school. / Cost / Termly or one-off payment?
Provision of school uniform:
School Cardigan/Jumper
School Shirt
Other: please supply details: / Quantity
Quantity
Transport costs associated with travel to/from school (or to/from a partner educational organisation delivering a vocational course)
Please supply details of transport used (e.g. school bus) and distance to school: / £
Termly
One-off
Personal Protective Clothing (such as chef’s whites, tools etc) or necessary clothing required for a course. Please supply details: / £
Termly
One-off
Books, materials and equipment needed for a particular course. Please supply details: / £
Termly
One-off
The cost of essential educational visits related to courses. Please supply details: / £ / One-off
Other costs. Please supply details: / £
Termly
One-off
TOTAL / £
SECTION 4: Information and Conditions
·  If your application for an award is successful it will be made in three installments if the amount requested is more than £50, unless your request is for a single award to help with purchasing school uniform or equipment costs in which case the school may purchase the items on your behalf.
·  Books, reference materials and non-consumable equipment purchased by the school will be the property of the school and must be returned to the school at the end of the course.
·  Support is subject to funds being available at the time your application is received and assessed. This is a limited fund and once exhausted no further funding will be available. You should, therefore, be aware that a financial reimbursement for your expenditure is not guaranteed.
·  If an award is made, you should be aware that it may not be possible to provide the full amount requested.

PLEASE TURN OVER FOR DECLARATION AND SIGNATURE

SECTION 5: Declaration
·  I/we declare that the information we have given in support of this application is correct and complete to the best of my/our knowledge and belief.
·  I/we will inform you immediately of any change in circumstances at any time, which might affect my entitlement to support (for example if the student leaves The Blandford School or we are no longer eligible for the funding).
·  I/we understand that this information will not be shared with third party organisations, except for audit purposes.
·  I/we understand that non-attendance and non-compliance with the school’s code of conduct may result in loss of financial support.
·  I/we have read the Information and Conditions in Section 4.
·  If a cash sum is awarded, payment will be by cheque made payable to the parent/carer making this application. If you wish the cheque to be paid to a third party, please provide full details below: (Please check name is entered in Section 1b.)
Cheque payable to:
Name of Applicant
Signature: Date / If returning this form via email, please type your name, the date and tick the box.
Printed forms should be signed.
Office use only / Date received: / Signature:
Comments: / Date: / Signature:
Final decision:
AWARD – FULL AMOUNT
AWARD – PARTIAL AMOUNT - £
REJECT – provide reasons / Date: / Signature: