16-19 Bursary Application Form | Hall Cross Academy

First Name *

Middle Name

Last Name *

Year Group *0 / 6

Date of Birth *

Age as at 31 August 2023 *

Street Address *

City *

ZIP / Postal Code *

Country

Home Telephone *0 / 11

Student Mobile *

Student School Email AddressIf unknown this will be input by the office

Have you the right of abode and been resident in the UK for the last 3 years? *

Please tick the appropriate box and complete the corresponding section. I am applying for:

Section 2 - Discretionary Bursary

I am receipt of free school meal *

My family is in the receipt of one or any of the following: *universal credit, child tax credit, working tax credit, pension guarantee credit, employment and support allowance, job seekers allowance or support under part IV of the Immigration & Asylum Act 1999

Please provide evidence of benefits e.g. Universal Credit Statement, Tax Award Letter dated 6 April 2022 - 5 March 2023 *

If your evidence is universal credit please upload 3 full statements please. Also if your evidence is tax credit please upload all 6 pages of the award letter.

Total family household income is below £27,500 *

Please provide proof of income e.g. most recent P60 or self-employed tax return *

Single parent family/Young carer/ Young parent *

Please indicate number of dependent children which are living in the same household: *

Section 3 - High Priority Bursary

I am currently in Local Authority Care *

Please provide a letter from the Local Authority Care *

I am currently living independently having left Local Authority Care *

I am currently in receipt of Income Support or Universal Credit in my own right *

Please provide a supporting documents of Income Support and Universal Credit *

If your evidence is universal credit please upload 3 full statements please. Also if your evidence is tax credit please upload all 6 pages of the award letter.

I am receipt of Disability Living Allowance or Personal Independence Payments in my own right as well as Employment and Support Allowance or Universal Credit *

Please provide a supporting documents of Disability Living Allowance, Personal Independence, Employment and Support Allowance or Universal Credit *

Section 4 - Details of Financial Assistance Required(All Applicants must complete)

The amount of financial assistance you will receive is dependent on your personal circumstances. It is intended to help you with the costs of overcoming any barriers you may have when attending sixth form. Using the options below, please tell us what you might need financial assistance for and how much you believe you will need during the academic year. This information is strictly confidential and will only be used for this assessment purpose.

Travel to and from Hall Cross Academy *

GBP

Uniform *

GBP

School Meals *

GBP

Trips *

GBP

Equipment/Books *

GBP

Other *

GBP

Please Specify

Student Bank Details

Bank Name *

Account Name *

Account Number *0 / 8

Sort Code *0 / 6

If account is a building society account, also provide roll number

Learner Declaration

I declare that the information on this form is true and accurate to the best of my knowledge. I have made this claim for a Bursary payment, fully aware that any false statements can lead to withdrawal/refusal of any financial support and may lead to me being prosecuted. I understand that if I refuse to provide information which may be relevant to my claim, the application will not be accepted. I understand that monies I receive under the Bursary Scheme will be paid on condition of standards of attendance and behaviour. The bank account details provided must be in my name. I will attend regularly and complete the course for which my bursary is supporting me. When changes to my household financial circumstances occur (which may result in changes to my claim), I confirm I will notify my provider immediately. I will notify my provider immediately with any changes to my Bank/Building Society details. I understand that monies I receive under the Bursary Scheme have been awarded to provide me with financial support to allow me to continue in learning and if I leave learning all financial support will stop. I understand that I do not have an automatic entitlement to Bursary payments and all payments are based on the information I have provided. I am clear that the Bursary payments I receive are to provide me with the means to remain in learning and are to be used for items such as: books, equipment, travel costs, meals, compulsory trips, etc. I understand I have the right to appeal if I disagree with the outcome of my Bursary Application. This appeal should be made to my provider but if I feel I have not been treated fairly, I can follow the Complaints Procedure. I understand that this application process will be repeated for each year of study. I understand that I will be required to provide receipts to prove my bursary spending has been in support of my education.

Applicant Signature *

Parent/Carer or Key Worker Signature *

Date *