Bursary Fund Application Form 2014/2015




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16-19 Bursary Fund Application Form

2014/2015




Please note the following important information:



  • You should read the 16-19 Bursary Policy 2014-15 to make sure you are eligible to apply.

  • Please complete all sections of the form and make sure you provide us with copies of the evidence we need. Your application will not be assessed without the correct evidence.

  • The closing date for applications is Friday 24th October 2014.

  • The budget we have available is limited so we cannot guarantee that we will be able to provide you with the financial support you request.

  • Payments of all bursaries are dependent on you maintaining attendance of 95% or above on all your courses and behaving appropriately in the UTC.

When you have completed this form please return it, fully completed with evidence, to the main reception.








Section 1: Personal Details





Full Name:







Date of Birth:







Gender: Male ☐ Female ☐










Your current address:









Your term time address (if different to your current address):







Your parent(s) / guardian(s) name(s) and address(es):














Your Telephone Number(s):





Your Email Address:






Section 2: Residency





Please select which of the following applies to you:
British Citizen

EU / EEA Citizen

Refugee

Asylum Seeker

Indefinite Leave to Remain

Other (please specify)














Have you been resident in the UK or EU/EEA for the last 3 years?
Yes ☐ No ☐








Section 3: Guaranteed Bursary


Are you (the student): Please only tick a box if you are answering “yes”
In Care ☐ A Care Leaver ☐ In receipt of Income Support ☐
In receipt of Employment Support Allowance and Disability Living Allowance or Personal Independence Payment ☐
If you have ticked any of the boxes above please go straight to section 7 of this application. If the above does not apply to you please continue to Section 4.





Section 4: Discretionary Bursary (you only have to provide evidence for one of the categories but please answer all questions)





Did you receive free school meals in Year 11: Yes ☐ No ☐









Are you, or your parent(s)/carer(s), in receipt of one or more of the following benefits:
Income Support
Income-based Jobseekers’ Allowance or Employment and Support Allowance
Support under Park VI of the Immigration and Asylum Act 1999
Guaranteed Element of State Pension Credit

Child Tax Credit, provided they are not entitled to Working Tax Credit and have an annual income (as assessed by HMRC) that does not exceed £16,190


Universal Credit





(Please tick all that apply)











Are you, or your parent(s)/guardian(s) not in receipt of one of the benefits listed above but are employed or self-employed with a gross household income of less than £16,190? Yes ☐ No ☐







Are you a young parent? Yes ☐ No ☐







Are you a young carer? Yes ☐ No ☐



Section 5: Funding Requirements





I live more than 2 miles from College and would like help with my travel costs.
Yes ☐ No ☐









I would like to apply for support with food costs. I have included evidence of either FSM or my status as a young carer with this application form.
Yes ☐ No ☐

There may be other costs which occur throughout the year. We appreciate that you may not know these costs at the time of completing this application so at present we will only consider support in relation to the questions asked above. If you have other UTC-related costs in the future then you will need to inform your Tutor who will explain the process.


Section 6: Additional Information





Please use this space here to give us any additional information you think may support your application:







Section 7: Bank Details


Please fill this section in carefully and ensure the information you provide to us is accurate. The details given here must relate to your own bank account and not a third party.
Nrectangle 1ame of Account Holder
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Address of Account

Holding Branch
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Sort Code

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Account Number
Trectangle 7ype of Account

e.g., current or savings






Section 9: Student & Parent/Guardian Declaration



This declaration must be signed by all students. If the income evidence provided belongs to parent(s)/guardian(s) then we must also have a parent/guardian signature.
I/we certify that the information given is, to the best of my/our knowledge and belief correct.
I/we understand that payments may be delayed or stopped if I do not maintain the minimum UTC requirement of at least 95% attendance on all my courses.
I/we undertake to inform the UTC immediately if I, the applicant, decide to leave my course.
I/we understand that if the applicant leaves their course of study before completion, the UTC will attempt to re-claim any monies allocated.
Student’s Signature ………………………………………………. Date: / /
Parent/Guardian’s Signature …………………………………….. Date: / /






OFFICE USE ONLY

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Student Reference Number


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Date Application Received



Application Status


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Complete Incomplete



If incomplete please give more information here e.g., information or evidence required / action(s) taken. Please also include staff initials for any actions taken:





Allocation of Funds

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Travel: Distance (miles) Termly Amount

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Food: Yes No Termly Amount

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Panel member 1:

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Panel Member 2:

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Date decision letter sent:


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