16-19 Bursary Policy Approval Form
Apply for the 16-19 Bursary by completing your details and submitting supporting documents.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Contact Mobile Number
*
Please enter a valid phone number.
Format: 00-000-000-000.
Student Email Address
*
example@example.com
Section 2
Vulnerable Bursary - please complete section 3, 5, 6 and 7
Discretionary Bursary - Please complete section 4, 5, 6 and 7
SECTION 3 - Vulnerable 16-19 Bursary (£1,200 p.a.) - The student who is applying for the award should tick the boxthat applies to them (please attach proof - see section 5):
I am living in care
I am a care leaver
I am in receipt of Income Support or Universal Credit in my own name
I am in receipt of Disability Living Allowance or Personal Independence Payments in my own name, andI am also in receipt of Employment and Support Allowance or Universal Credit in my own name
SECTION 4 – Discretionary 16-19 BursaryI am a student who permanently lives in a household whose parents/guardians receive one of thefollowing (please tick the appropriate box): Name of first person receiving benefit
First Person:
FreeSchoolMeals
IncomeSupport /UniversalCredit
Job Seeker'sAllowance
EmploymentSupportAllowance
Support under Part VIof the Immigrationand Asylum Act
Name of second person receiving benefit (if applicable)
Second Person:
FreeSchoolMeals
IncomeSupport /UniversalCredit
Job Seeker'sAllowance
EmploymentSupportAllowance
Support under Part VIof the Immigrationand Asylum Act
Name of third person receiving benefit (if applicable)
Third Person:
FreeSchoolMeals
IncomeSupport /UniversalCredit
Job Seeker'sAllowance
EmploymentSupportAllowance
Support under Part VIof the Immigrationand Asylum Act
Name of fourth person receiving benefit (if applicable)
Fourth Person :
FreeSchoolMeals
IncomeSupport /UniversalCredit
Job Seeker'sAllowance
EmploymentSupportAllowance
Support under Part VIof the Immigrationand Asylum Act
SECTION 5 - Please enter the amount you consider your household income to be in the box below, together with any other information we should know. Please attach paper evidence to your application. Photocopies of evidence should be provided as documents will not be returned.
*
The option below shows the evidence you will need to provide with your application form. Once you have declared and identified your benefits/income on the application, find the type of income that applies to you in the first column, and the evidence required column will tell you what you need to provide. Then tick if you submitted this as evidence.
*
Universal Credit
Income Support
Job Seekers Allowance
Employment Support Allowance
Incapacity Benefit
Personal Independence Payment
Carer's Allowance
Child Tax Credits
Grants or bursaries etc.
Disability Living Allowance
SECTION 6 – Student Bank Account Details (proof is required) - Bank Name (e.g. NatWest)
*
Branch Location
*
Name of Account Holder
*
Sort Code
*
Account Number
*
Roll Number (building society accounts)
SECTION 7 - DECLARATION The Bursary fund will assist me in purchasing or paying for the following items: Item 1
*
Item 2:
Item 3:
Item 4:
Add any other items you think is relevant
Signed (Student):
*
Upload Supporting Documents
*
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of
Parent / Guardian Name
*
First Name
Last Name
Parent / Guardian Email
*
example@example.com
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