Outward Bound Scholarships Application Form

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Outward Bound Scholarships Application Form Powered By Docstoc
					Ashburton Jaycees Education & Development Fund
 And Advance Ashburton Community Foundation

Outward Bound Scholarships

         Application Form

            Outward Bound Scholarship
               Advance Ashburton
                   PO Box 310
                    Ashburton
                   Ph 302 3858
           Email advanceacf@xtra.co.nz

         Enquiries always welcome




                  Version 2010
Section 1: APPLICANT DETAILS

Application for a grant for the Outward Bound eight day “Discovery” course at Anakiwa


Full Name


Date of Birth                                                                    Gender:         Male               Female


Address




Contact Telephone                                                                Mobile


Email


Occupation or
Training


Residency                         Permanent resident of Mid-Canterbury?                     Yes / No
                                  No. of years in Mid-Canterbury?

Medical                           Do you have any health or personal issues that might affect your acceptance on an
                                  Outward Bound Course?                                     Yes / No
                                  Before commencing the Outward Bound course all participants must complete an
	           	           	         official	Outward	Bound	medical	with	a	doctor.	See	www.outwardbound.co.nz for
                                  more information.

Section 2: EDUCATION AND WORK SUMMARY


    Education          School / Institution       Course details, certificates and                      Started       Finished
    Summary                                       qualifications achieved
    Tertiary




    Secondary




    Other




                Please post the complete application form to: Advance Ashburton Community Foundation PO Box 310 Ashburton
 Work            Employer                   Industry                  Position held              Started        Finished
 History
 Currently




 Previously




 And before
 that?




Section 3: PERSONAL ACTIVITIES & COMMUNITY INVOLVEMENT

List any interest/hobbies/sports and community service you currently have:




Section 4: GOALS/ASPIRATIONS

Please list in detail your personal and/or work goals or aspirations:
What are your three (3) most immediate goals?




What are your long-term ambitions?




How do you think the Outward Bound course will help you reach your goals and ambitions?




Other comments




           Please post the complete application form to: Advance Ashburton Community Foundation PO Box 310 Ashburton
Section 5: REFEREE DETAILS (At least one work referee please)

Name                                                    Address

                                                        Relationship
Phone                                                                                                    Years known
                                                        to applicant

Name                                                    Address

                                                        Relationship
Phone                                                                                                    Years known
                                                        to applicant



Section 6: GENERAL INFORMATION

How did you find out about the Outward Bound Scholarship?

         Ashburton Guardian                             Friends/Family                        Employer

         Internet (Please specify website)

         Other (Please specify)




Section 7: DECLARATION AND PRIVACY ACT 1993 AUTHORISATION

This authorisation relates to information in this application that Advance Ashburton Community
Foundation (“Advance Ashburton”) may hold about me now or in the future.
•	   I reside in Mid-Canterbury and I am aged between 27 and 40.
•	   I give	permission	to	Advance	Ashburton	to	make	independent	confidential	inquiries	relating	to	my	application.
•	   I understand that if I am awarded a Jaycee Outward Bound Scholarship this does not constitute acceptance
     onto	an	Outward	Bound	Course	and	I	accept	that	I	am	responsible	for	and	must	meet	the	fitness	and	any	other	
     requirements	as	deemed	necessary	by	Outward	Bound	for	acceptance	and	attendance	on	a	course.
•	   If successful I authorise Advance Ashburton to use my name/photograph for publicity purposes and also to
     participate	in	promotional	work	as	may	be	reasonably	required	by	Advance	Ashburton,	free	of	charge.
•	   If successful I agree to provide Advance Ashburton with a written report within 3 months of completing the course.
•	   If successful I agree to advise Advance Ashburton if I withdraw from undertaking the Outward Bound Course or I no
     longer reside in Mid-Canterbury.
•	   If successful I agree to act as a role model at all times and not to bring Advance Ashburton into disrepute.
•	   I accept	that	the	decision	of	Advance	Ashburton	is	final	and	no	correspondence	will	be	entered	into.
•	   I declare that the information contained is true and factual.



Full Name of Applicant


Signature                                                                            Date




           Please post the complete application form to: Advance Ashburton Community Foundation PO Box 310 Ashburton
                                                           GUIDELINES


Background

When Ashburton Jaycees wound up they established a Special Named Fund with Advance Ashburton Community
Foundation,	to	be	used	for	education	and	development	of	young	people	up	to	the	age	of	forty.	
This	year	income	from	the	fund	will	be	used	to	sponsor	places	on	the	eight	day	Discovery	Course	at	Outward	Bound,	
Anakiwa in the Marlborough Sounds.
This is a wonderful opportunity for individuals wishing to reach their full potential through challenge and adventure in
the outdoors.


Eligibility

Applicants (male or female) shall be between the ages of 27 to 40 and must reside in Mid-Canterbury at the time of
application.


Application Closing dates

Applications are considered once a year. For closing dates visit www.advanceashburton.co.nz


Value and Payment of Scholarship

•	   Full course costs shall be paid by the fund directly to Outward Bound on behalf of the applicant.
•	   Train fares from Christchurch to Picton and return shall be reimbursed to the successful applicant on production of
     a travel claim after attending the Course but it shall be the applicant’s responsibility and cost to travel to and from
     Christchurch.

Other Information

•	   An	interview	will	be	required	before	final	selection.
•	   A scholarship may be revoked if a recipient’s behaviour is inappropriate or the recipient has breached the conditions
     of the Scholarship.
•	   It	is	expected	that	the	Outward	Bound	course	will	commence	within	12	months	of	final	selection.
•	   Recipients	shall	be	responsible	for	providing	all	gear	required	for	the	course	although	Outward	Bound	have	some	
     available.
•	   Recipients shall be responsible for completing the Outward Bound Application Form and Medical Questionnaire at
     least 2 weeks prior to the closing date for the Course.
•	   Recipients shall complete a written report to Advance Ashburton Community Foundation within 3 months of
     completing	the	course	outlining	the	benefits	gained	from	attending	the	course.
•	   Recipients may be asked by Advance Ashburton to participate in promotional activities as agreed by both parties.


What we are about

Advance	Ashburton	Community	Foundation	has	been	formed	as	a	perpetual	charitable	trust	dedicated	to	benefiting	the	
Ashburton district. It is registered as a charity under the Charities Act with number of CC28482.

Donated funds are invested and the Foundation distributes the income to worthwhile community organisations and
causes,	after	allowing	for	inflation.	It	takes	time	for	funds	to	grow,	but	the	long	term	benefits	to	the	Ashburton	district	
will be substantial.




              Please post the complete application form to: Advance Ashburton Community Foundation PO Box 310 Ashburton

				
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