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					The Helen Betty Osborne                         The report of the Aboriginal Justice
Memorial Foundation was                                Inquiry concluded racism, sexism
established by an Act of the 2nd                             and indifference marked
Session of the 37th legislature                                 these events.
of Manitoba, December
2000 under the auspices                                           This foundation in
of the Attorney Genera of                                          awarding bursaries to
Manitoba.The purpose of                                            deserving Aboriginal
the Foundation is to provide                Helen Betty            students strives to
financial assistance to                     Osborne                promote the memory
                                            memorial
 Aboriginal Persons residing                Foundation            of Helen Betty Osborne.
 in Manitoba who are enrolled
  in post-secondary studies                                     It also acknowledges
    in Manitoba.                                              deserving Aboriginal students
                                                          who are making a difference in
        The Act acknowledges Helen               eliminating the barriers of racism, sexism
           Betty Osborne’s goal of              and indifference in the society we live in.
             becoming a teacher before
              her untimely death in 1971.
               The events that followed
               resulted in concerns
               about the relationship
               of the justice system
              and Aboriginal people.
Helen Betty
Osborne
memorial
Foundation




Please fill out the application completely. Answer each question. If a specific question does not
apply, enter not applicable or N/A.


Name

Email

Age

Address

City	    	        	       	   	       	       	       	      Province

Postal	Code

Telephone


Required:
Proof of Aboriginal Ancestry (Please include a photocopy of registration/membership card)

Aboriginal Affiliation:
	        First	Nation
	        Metis
	        Inuit


Band	Province

Nationhood



State	Metis	Association,	Province	and	Membership	Number

Band/Community	Name

Registry	Number
                                                       Program Education
                                                         Program of Study
Helen Betty
Osborne
                                                                                     FORm
memorial
Foundation




Acceptance by Institute Confirmed                Yes              No

Name	of	Institution		    	        	      	       	        	       Course	of	Study

Entering Year            Length of Program

Accreditation,	upon	completion



Education History
Level of Education                       List of Certificates or Degrees



Recent	Grade	Point	Average*																									*Required: Attach copies of Grade Transcripts



Education Details
What	Secondary	School	did	you	attend?

Year of Graduation

Have you received any awards or other recognition for your academic work?           Yes             No

If yes, please provide details:



Please tell us your career plans after you graduate from this program of study:



Community Service History
Please describe your involvement within the Aboriginal community or other volunteer experiences:
Helen Betty
Osborne
memorial
Foundation




Employment History
(This information is strictly confidential)



Name	of	Employer	

Contact

Address	




Phone



Annual Income (after taxes):


Name	of	Employer	

Contact

Address	




Phone



Annual Income (after taxes):



Have you had a summer job?                    Yes   No

Have you held a part-time job?                Yes   No

If Yes, how much did you earn during that year?
Helen Betty
Osborne
memorial
Foundation




Funding from other Sources
Are you recieving funding assistance from any other sources for your studies?    Yes        No

If	yes,	from	whom?



Amount	Received



Have you approached your Band/Community or Metis Association for funding?       Yes         No

If No, please state why:




If Yes, please provide contact information:

Name of Band/Community:

Contact	Name	 	            	     	       	      	       Phone	


What other funding sources have you explored? (examples: Corporate Scholarships, Student Loan,
University Bursaries, etc.,)

Corporate/University/Scholarship	Name	 	

Contact	Name	 	            	     	

Phone


Corporate/University/Scholarship	Name	 	

Contact	Name	 	            	     	

Phone
Helen Betty
Osborne
memorial
Foundation




Family Income
Annual Family Income:                                       After taxes, this is strictly confidential



Father’s Employer                                           Phone

Mother’s Employer                                           Phone

Partner’s Employer       	        	        	       	        Phone

Is your family or partner able to contribute to your training?                Yes                No

If No, briefly explain why?



If Yes, how much are family/partner contributing? $


(Note: include this amount under “income” on the budget page)




Please list all of your dependents:
            Helen Betty
            Osborne
            memorial
            Foundation




 Description of Eligible Expenses
 for Education and or/Training Period                 Monthy Cost   Number of Months   Total Cost

Rent

Food

Utilities

Telephone (Basic Service only)

Transportation

Tuition/Training Costs

Course Material Costs

Child Care Costs

$_______x per child x______of Children = $_________

Other costs, Please describe


 Total Eligible Expenses


  Description of Income                                             Number of Months   Total Cost

Band or Community
Funding for Tuition and Book Supplies

Band or Community Living Allowance i.e. Stipend

Other Bursariers or Scholarships
Identity Source

Child Benefit Allowance

Partner or Family Contributor

Personal Contributions/Summer or Part-Time Work

Student Loan

Other income

Total Eligible Expenses

Total Income

Difference between Income and Expenses

Total Amount Requested
            Helen Betty
            Osborne
            memorial
            Foundation




 Description of Eligible Expenses
 for Education and or/Training Period             Monthy Cost   Number of Months   Total Cost

Rent                                                  $400.00         8            $ 3,200.00

Food                                                  $400.00         8            $ 3,200.00

Utilities                                             $ 50.00         8            $     400.00

Telephone (Basic Service only)                        $ 30.00         8            $     240.00

Transportation                                        $ 90.00         8            $     720.00

Tuition/Training Costs                                0               0            0

Course Material Costs                                 0               0            0

Child Care Costs

$150.00 x per child x 2 of Children = $300.00         $300.00         8            $ 2,400.00

Other costs, please describe                          0               0            0


 Total Eligible Expenses                              0               0            $13,660.00


  Description of Income                                         Number of Months       Total Cost

Band or Community
Funding for Tuition and Book Supplies                                0             $ 3,300.00

Band or Community Living Allowance i.e. Stipend                      8             $ 5,400.00

Other Bursariers or Scholarships
Identity Source                                                      0             0

Child Benefit Allowance                                              8             $     800.00

Partner or Family Contributor                                        0             0

Personal Contributions/Summer or Part-Time Work                      2             $     500.00

Student Loan                                                         0             0

Other income                                                         0             0

Total Eligible Expenses                                              0             $10,000.00

Total income                                                                       $13,660.00

Difference between Income and Expenses                                             $ 3,660.00

Total Amount Requested                                                             $ 1,500.00
  Helen Betty
  Osborne
  memorial
  Foundation




Please	use	this	space	to	introduce	yourself	to	the	jury	or	you	can	attache	a	typed	page	with	your	
application.	Include	any	information	that	will	help	you	make	a	compelling	case	to	support	your	particular	
training and any special considerations the jury should know:




References: Educator, Employer and Community Member below:
Name:                            Relationship to Applicant:
Address:
Daytime Phone:


Name:                            Relationship to Applicant:
Address:
Daytime Phone:


Name:                            Relationship to Applicant:
Address:
Daytime Phone:
Helen Betty
Osborne
memorial
Foundation




 Please send the following to
 The Helen Betty Osborne Memorial Foundation:
 	       •	Your application
 	       •	Your reference letters from Educator, Employer, Community Member
 	       • Grade Transcripts (Copies accepted)
 	       •	Letter confirming your admission to a program or continued enrollment.
 	       •	Proof	of	Aboriginal	ancestry
 	       •	Resume	or	curriculum	vitae
 	       •	A	Statement	of	Introduction;	please	include	information	and	special	considerations
 	       		that	will	make	your	request	compelling	to	the	jury/selection	committee.



 All support material is due on the deadline date,
 August 31st of each year.

 If you are awarded Financial Assistance:

 	       You may be required to submit a financial accounting award as well as an activity
 	       report.	Bursaries	are	deemed	as	income	under	the	Income	Tax	Act	and	must	be	
         reported as such. You will receive a T4A from the HBOMF in respect to your award.


 Please send your application and other materials by mail or courier to:

 	       	       	       Helen Betty Osborne Memorial Foundation
                         235-405 Broadway Avenue
 	       	       	       Winnipeg,	Manitoba
                         R3C 3L6


 You can submit application and other materials by email:

 	       	       	       sdelorande	@gov.mb.ca
                         Phone: 204-945-3909
                         Fax: 204-948-2150


 	       	       	

				
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