Dylan Alcott Foundation Scholarship Application Form Required fields are marked with an asterisk (*). Citizenship * I am a domestic student I am an international student International students please visit the International site. Age I am under the age of 26 years old I am over the age of 26 years old Sorry, you are not eligible. Please confirm you are a new student. Students who have a new course offer through VTAC, UAC or direct through La Trobe for 2024 are considered new students. Students who have studied at least one semester or have course transferred are continuing. Continuing students are not eligible at this time. New Continuing Sorry, you are not eligible. My detailsGiven name * Family name * Student ID number Please add if you have a La Trobe student ID or leave blank if not. Email * Phone * Date of Birth * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Gender * Female Male Neutral/Indeterminate/Intersex/Unspecified Street address City / Suburb / Town Postcode Supporting information Indicate which degree you will be studying or planning to study in Semester 1, 2024 * Please provide a personal statement about reasons for studying your chosen field, career aspirations and what receiving the Dylan Alcott Foundation Scholarship would mean. * (Max 500 words) Please provide a reference written by someone who is familiar with your work, character, background, attributes, and accomplishments. * For example: employer, teacher, community leader, friend not related to you, health care worker, on letterhead or include contact details of referee. Letter must have a current date. Are you living with disability, either physical or non-physical as defined by the Disability Discrimination Act 1992? * Yes No Briefly describe your disability, the impact, timing and how it has adversely affected your education or ability to pursue education. You must include the duration and the impact of your condition. (to receive consideration for this criterion, you will be required to provide evidence, see below) Max 2500 characters Statement of support from a medical professional. You must provide a recent (within 12 months) statement of support from a medical professional who treated or is currently treating your condition(s)/disability. Ensure the contact details of the professional and date is included. PLEASE NOTE: .pdf file type ONLY. Max file size 8MB. Are you or will you be the first person in your immediate family to attend university? * (immediate family = parents, brothers, and sisters) Yes No Are you of Aboriginal Australian or Torres Strait Islander descent? * Yes No Have you ever spent time in formal out-of-home care? * e.g. foster care, residential care, kinship care or been a ward of the state. Yes No Specify the type of care How long were you in formal out-of-home care? Are you or have you been a refugee? Yes No What is your household structure? Live alone Live with flat mates Live with my spouse/partner Live with parents/guardians Live in single parent/guardian household Do you have children? Yes, I have children No, I do not have children Parenting I am a sole parent I share custody of children The number of children less than 16 years of age The number of children 16 years of age or older Has your education been adversely affected by your financial circumstances, or do you expect your tertiary education to be adversely affected by your financial circumstances? You will be required to provide evidence Yes No Do you, the applicant, currently receive any Centrelink benefits? e.g. Youth Allowance or health care card Yes No Please provide evidence of your current Centrelink benefit(s) such as an Income Statement dated within the last three months or both sides of your current Health Care Card. For information on suitable evidence check our supporting documentation requirements website. (.pdf, .doc, .docx, .jpg or .png file types only. Max file size 8MB) Upload the other side of your current Health Care Card. Please explain why you are not in current receipt of Centrelink benefits. Please describe the financial hardship you have experienced and how this has affected your education or ability to pursue education You will be asked to provide evidence below. Evidence includes 3 payslips or Notice of Assessment from the Australian Taxation office. If you are not in receipt of Centrelink benefits, please provide proof of your financial situation. Evidence can include copies of your last 3 payslips, or a copy of Australian Tax Office Notice of Financial Assessment, these can be yours or the people you are financially dependent on. If you are uploading more than one document, we suggest that you save the pages together in pdf as you can only upload once in this section(.pdf, .doc, .docx, .rtf, .txt, .jpg or .png file types only. Max file size 8MB) Has your education been disadvantaged by difficult circumstances not outlined above? (examples of difficult circumstances may include abusive family circumstances, excessive carer duties, chronic medical condition of a child, death of close relative, homelessness, recent multiple relocations, recent separation of parents, relationship breakdown, victim of crime, bullying.) Yes No Please describe the impact and timing, and how it has adversely affected your education or ability to pursue education. (to receive consideration for this criterion, we require supporting evidence, see below) max. 250 words Please provide a statement of support about your difficult circumstances. (This may be in the form of a SEAS Statement, death notice, police report or statement by a relevant responsible person. For example; health care professional, social worker, counsellor, religious or community leader, school principal or teacher etc, unrelated to you as the applicant, who can verify the circumstances. Statements of Support must be recently dated (within 12 months), on letterhead or include contact details of referee. Statement must include duration and impact of the circumstances. *Applicants who do not supply supporting documents will not be scored for difficult circumstances. .pdf, .doc, .docx, .jpg or .png file types only. Max file size 8MB) By submitting this applicationI understand and consent to the release of my information and scholarship application to the Dylan Alcott Foundation, for the purpose of scholarship recipient selection and if successful, promotional media use. * Yes I consent to provide annual milestone reports to La Trobe for the Dylan Alcott Foundation, receive a phone call and/or meet with a representative of the Dylan Alcott Foundation and participate in media releases as required, including attending functions for promotional purposes. * Yes I consent to having my name and photo used on the Dylan Alcott Foundation website as a scholarship recipient, for promotional purposes. * Yes I confirm that all information in this scholarship application is correct and factual. I acknowledge that if this information is found to be misleading or incorrect the scholarship may be terminated. * Yes I confirm that I am living with disability, either physical or non-physical as defined by the Disability Discrimination Act 1992. * Yes Privacy All information provided by applicants will be treated as confidential. At La Trobe University, we respect the privacy of your personal information. We collect personal information in your application to determine your eligibility for a scholarship, bursary or grant, and to assess your application as part of the ranking and allocation process. In accordance with privacy laws, personal information about you contained in your application will not be used for any other purpose or disclosed to any person who is not part of the La Trobe assessment and allocation process, without your permission. You may have the right to access personal information we hold about you, subject to any exceptions in relevant laws, by contacting the Scholarships Office. The La Trobe University privacy policy can be viewed at: www.latrobe.edu.au/privacy Validation
