La Trobe Access Scholarship Application Form This form is for Indigenous students only. 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 enrolled or planning to enrol via one of these pathways or University entry schemes? * -- Please Select --I am applying to the university based on my work and life experienceI have completed Year 12 at least two years ago and I am using my ATAR as the basis of admission to the universityI am completing a TAFE or VET pathway programI am enrolled in the Tertiary Preparation Program (TPP)None of these Are you the first person in your immediate family to attend university? * (immediate family = parents, brothers, and sisters) Yes No Do you speak another language at home other than English? * Yes No What language? 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? 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. 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: Financial circumstance 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. Austudy, ABSTUDY, Job Seeker or Family Tax Benefit) -- Please Select --YesNo Please provide evidence of your Centrelink benefits such as an Income Statement dated within the last three months OR a copy 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) Please provide the following information regarding your financial circumstances. What is the gross income of your household? Household income includes you, your parents or guardians, or your partner. -- Please Select your gross family income before tax --$0-20000$20000 – 30000$30000 – 40000$40000 – 50000$50000 – 60000$60000 – 70000$70000 – 80000$80000 – 90000$90000 – 100000$100000 – 110000$110000 – 120000$120000 + How many household members (including yourself) are dependent on the household income selected above? -- Please Select --123456789 or more Please provide evidence of all household income contributors. * (e.g. Australian Tax Office Notice of Assessment for 2020-2021, or 3 consecutive pay slips dated within the last 3 months, .pdf, .doc, .docx, .jpg or .png file types only. Max file size 8MB) What percentage of your weekly income is spent on rent/mortgage payments? * -- Please Select --0-29%30-50%51-100% Other difficult circumstances 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 criteria, we require supporting evidence)* Personal statement 2500 characters Provide supporting documentary evidence. * (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 dated, 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) 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
