Section 1 - Student Details Please complete all the details in full. If you do not provide the information requested your application may be delayed or not approved.
First Names...................................................................
Post Code...............................................
Home Telephone...........................................................
Mobile Phone…………………………..…
Date of Birth..................................................................
Age at 31/08/15.......................................
Section 2 - Support Requirements Please indicate in the table below, one or more of the items that you are requesting support for. (A)Travel Support
(B) Books & equipment
(C ) Trips
Yes
Yes
Lives further than 2 miles from school
E.g. Exam Costs Course related Trip / Equipment/ Please specify: Uni visits Please specify incl. costs:
Yes
(D)Meal Support
Yes
Guaranteed Bursary
In Care A care leaver In receipt of Income Support / Universal Credit Disabled and in receipt of both ESA and DLA / PIP*
Section 3 - Your Living Arrangements Please tell us about your living circumstances
Living with parents / guardians Living independently (with friends / partner / alone) In Local Authority care None of the above apply
*ESA (Employment Support Allowance), DLA (Disability Living Allowance), PIP (Personal Independence Payment) Page 1 of 5
Section 4 - Residency Status Please tick those that apply
British Citizen EU/EEA Citizen Asylum Seeker Refugee/Indefinite Leave to remain Discretionary leave to remain Other Section 5 - Income Information & Evidence ( to be completed by parent/carer)
For evidence requirements, please see the full guidelines. All payslips or letters must be provided in full. Incomplete evidence will not be accepted. Do you receive any of the following? Income support Income- based Jobseekers Allowance Pension Credit Income related Support Allowance What was your TOTAL household income for the Tax Year 2015-2016
£
The following are acceptable formats of evidence: - Payslips - P60 - Full copies of benefits confirmation letter. The following benefits apply: - Income Support - Income Based Job Seekers Allowance - Tax Credits - Employment and Support Allowance - Guaranteed Element of State Pension Credit - Housing Benefit or Council Tax Benefit Section 6 - Declaration -
I/We attach full evidence of eligibility for a Higher Level/Discretionary Bursary as detailed in the associated guidance. I/We understand that if I give false information or withhold information, my application will be cancelled and, if necessary, action will be taken to recover any money paid to me. I/We understand that payment of the general bursary is discretionary and is dependent on the attendance criteria as detailed in the bursary guidance. I/We understand that relevant information regarding my application may be shared with other agencies such as the Education Funding Agency. I/We understand that my bursary will cease if I leave school before I have completed my studies.
Print (Student) Name ………………………….Signed………………………… Date....................... Print (Parent/Carer).......................................Signed……………………..…..Date……………….
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Section 7 – Bank/ Building Society Details
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Please check that your account can accept BACS Direct Credits.
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Please note for security reasons this page will be detached from your application form and be retained by our Finance Department
Student Name(as appears on bank account)
Bank/Building Society Name
Name of Account Holder
Sort Code
Account Number
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CHARTERS SCHOOL 16-19 Bursary Contract By completing this Contract you agree to the terms and conditions under which you will be paid your 16-19 Bursary. Any change in financial/home situation should be communicated to School in writing. Parents/ students are required to sign to this effect and if upon review it is found that student/parents have falsified documents, submitted inaccurate information or been claiming money fraudulently the school may refer the matter to the police. It is an expectation that you will spend the 16-19 Bursary to support your education and should cover such outgoings such as transport costs, books and equipment, trips and other course related costs.
Student declaration:
I am a full time student attending Charters School. I agree to abide by the terms and conditions of this contract and understand that the payment of the 16-19 Bursary is subject to a review before each payment. I risk losing a payment should I fail to meet any of the conditions set out below:
Must meet punctuality and attendance requirements of at least 90% Ensure work is completed to appropriate level and submitted within required deadlines Behave appropriately and abide by requirements set out in the Sixth Form Agreement
Student signature: _____________________________________ Date: _________ Parent/carer signature: __________________________________ Date: _________ To be completed by Director of Sixth Form: I hereby confirm that the above named student has had the terms of the 16-19 Bursary explained and has agreed to comply with the conditions of this contract. It has also been explained that payment is subject to meeting the terms of this contract. Signature Director of Sixth Form: _____________________ Date: _________
Your completed application form, together with evidence of eligibility, should be returned to: Mrs Boxall, Sixth Form Administrator Charters School: a company limited by guarantee Registered in England: Company Number: 08208767 Registered Office: Charters School, Charters Road, Sunningdale, Ascot, Berkshire SL5 9QY
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FOR OFFICE USE ONLY
Date application received
£
Total household income declared
Y
Bursary application approved
£
Bursary Type Agreed
Total bursary award agreed
/
N
General (Discretionary Bursary) Travel (Discretionary Bursary) Trips Sixth Form Meals Guaranteed Bursary
