La Trobe Indigenous Access Scholarship Application Form Please ensure you have attached all of your supporting documents and wait for them to upload before you press submit. Applications that are submitted without supporting documentation will not be considered. For information on the types of supporting documentation please visit: supporting documentation. Required fields are marked with an asterisk (*). I am of Aboriginal and/or Torres Strait Islander Descent. * Yes No I'm sorry, you are not eligible for this scholarship. My details Given Name * Family Name * La Trobe Student ID # Gender * Female Male Neutral/Indeterminate/Intersex/Unspecified Date of Birth * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Email * Please use your La Trobe email if available Course Name * Campus * -- Please Select --Albury-WodongaBendigoMelbourne (Bundoora)Melbourne (City)Mildura SheppartonOnline Do you reside in a regional, remote or very remote area? * Check the Health Workforce Locator site (Check the 2016 box next the "ASGS Remoteness Areas") Yes No Suburb/Town Postcode Personal circumstance Are you the first person in your immediate family to attend university? * (immediate family = parents, brothers, and sisters) Yes No Do you have a medical condition or disability which impacts your ability to study? * Examples of medical conditions and disabilities include but are not limited to: Physical impairment (e.g. blindness), Learning disabilities (e.g. dyslexia), Chronic pain, Eating disorder (e.g. anorexia), Mental illness (e.g. depression), Major illness (e.g. cancer) Yes No Name of condition Duration of condition (months/years) Briefly describe your condition/disability and how it has adversely affected your education or ability to pursue education. Your personal statement must include the duration and the impact of your condition. (to receive consideration for this criteria, you will be required to provide evidence, see below) Personal statement 2500 characters You must provide proof of your medical circumstances such as a statement of support from a medical professional. * Applications submitted without medical evidence will not be scored for medical disadvantage. LAPs do not provide enough detail and are not recommended for submission. Family circumstance What is your Household structure? * Live alone Live in a share house 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 Number of children under 16 years of age: Number of children over 16 years of age: 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
