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					Date Rec.                               HC NH HCPC AC                          EBS No:




                  LEARNER SUPPORT FUND 2010/11
                                 APPLICATION FORM
        Please fill in all boxes. Any form not fully completed will be returned.
                          All information on this form is confidential.
SECTION 1: PERSONAL DETAILS
First Name(s)                                        Surname/Family Name

Date of Birth                                        Your Age on 6th September 2010

 Address for Letters                                 Telephone
…………………………………………………………                               Home………………………………………………….
…………………………………………………………                               Mobile…………………………………………………
Postcode …………………………………………….                          E-Mail…………………………………………………

Which campus/centre will you be studying at?
Highbury Campus (Cosham)                             Highbury City of Portsmouth Centre
Highbury Northarbour Centre                          Highbury Arundel Centre

Residential Status (please )                               Financial Status (please )
I am single and live with my parent(s)/guardian(s)          Supported by Parents/Guardians
I am single and live alone                                  Independent
I am married/live with my partner                           Supported by Partner/Spouse
Other (please state) ___________________                    Number of dependents

Optional (please )

    I am a lone parent
    I am a young carer
    I am in care/have left care within the last 12 months
    I left school before I was 16 (e.g. through pregnancy, parenthood, etc.)
    I have a mental health condition / learning disability / disability
    I was made redundant in the last 12 months (or am the dependent of somebody who was)
    I have no permanent home
    I am an ex offender / on probation

Have you lived in the UK or the EU for the last 3 years?                    Yes                 No

If you have answered NO to the above question, please tell us the date you arrived in the UK:

Date of Arrival
                                              Page 1 of 6
SECTION 2: COURSE DETAILS
  Full name of your course



 Are you a Full or Part-time Student?                                Full                         Part
 (Full-time is 16 or more hours a week)

 Start date of course                                        End date of course (if known)


 What year of study are you in? (of this course)
                                                         1                   2                3

SECTION 3: OTHER APPLICATIONS
 EMA: If you are 16-18 and studying for over 12 hours a week you may be eligible for Education Maintenance
 Allowance (EMA), which is a Government scheme where you could receive £10-£30 a week. For more
 information call EMA direct on 0800 121 8989, or pop into your school or college to pick up a form.

 Are you or will you receive Education Maintenance Allowance (EMA) for 2010/11?                                Yes
                                                                                                               No
 ALG: If you are 19 or older and you are studying your first full level 2 or 3 qualification you may be eligible to
 apply for the Adult Learning Grant (ALG) from the Learning Skills Council, which pays between £10 and £30 a
 week. For more information please contact ALG direct on 0800 121 8989.
                                                                                        Yes
 Are you or will you receive of an Adult Learning Grant for 2010/11?                    No
 PCC/HCC: If you are a Portsmouth resident residing in Post Codes PO1-PO6 or you reside in any other Post
 Code are in Hampshire and under the age of 19 you may be able to receive assistance with your travel
 expenses. For a full listing of the eligibility criteria please contact Portsmouth City Council and/or Hampshire
 County Council. If you reside in any other Post Code please contact your Local Authority for full details.
                                                                                                         Yes
 Are you or will you receive Transport Funding from PCC or HCC for 2010/11?
                                                                                                         No
 Care to Learn: If you’re under 20 and have one or more children, Care to Learn can help with up to £160 per
 week for the cost of your childcare while you're learning. For more information please contact Care to Learn on
 0800 121 8989.

 Are you or will your receive childcare support from Care to Learn?                     Yes
                                                                                        No
 Free Childcare for Training and Learning for Work: If you are 20 or over and have one or more children, the
 Free Childcare for Training and Learning for Work scheme could help with the cost of childcare while you learn
 or train. For more information please contact Care to Learn on 0800 121 8989.
                                                                                                Yes
 Are you or will you receive Free Childcare for Training and Learning for Work?                 No


 Other: Are you on a New Deal Programme, sponsored or have you applied for financial help                      Yes
 from any other organisation?                                                                                  No

 If you answered yes please state which organization and give brief details


                                                    Page 2 of 6
SECTION 4: FINANCIAL ASSESSMENT
 The figures you present should represent the 2009/10 financial year.
 PLEASE REMEMBER TO ATTACH PROOF OF INCOME FOR EVERYONE IN YOUR HOUSEHOLD
 INCLUDING BANK STATEMENTS (FOR LAST THREE MONTHS).
 We can accept photocopies of the bank statements, P60s, Working Tax Credits, Income Support
 Documents etc.

                                                               You Mother Father Guardian Partner
 Gross annual salary/wages BEFORE deductions
 Working Families Tax Credit
 Child Tax Credit
 Income Support
 Job Seekers Allowance
 Pension (company or private)
 Income from Self-Employment
 Taxable income from property
 Bank/Building Society interest
 Other taxable income (please specify)

 Please tell us about the expenditure in your household. Please indicate whether the figures
 you give are per week, month or year.

 Living Costs               Wk / Mth / Yr             Living Costs              Wk / Mth / Yr
 Food / household                                     Council Tax
 Gas                                                  Rent / mortgage
 Electricity                                          Transport / car
 Water                                                Other (please specify)
 Telephone                                            Total

         HAVE YOU REMEMBERED TO ATTACH PROOF OF INCOME?
             HAVE YOU TOLD US WHAT YOUR EXPENDITURE IS?
  ANY FORMS WITHOUT PROOF OF INCOME AND / OR EXPENDITURE DETAILS
                         WILL BE RETURNED
SECTION 5: SUPPORT NEEDS
 What would you like?
 If your application is successful what would you like help with? Please number 1-6 in order of priority
 (put 1 by the most needed item and 6 by the one you need least). Please leave blank the ones you
 don’t need.
 Help towards the purchase of a Bus Pass*:                Help towards Travel Expenses*
 Stagecoach                  First Provincial


 Help towards Essential Kit/Uniform                      Help towards the purchase of a bike

 (proof of purchase will be required)                    (proof of purchase will be required)

 Nursery Fees                                            Help towards the purchase of bike safety
 (please also fill in additional green form)             equipment
                                                         (proof of purchase will be required)
                                               Page 3 of 6
 *Please note that students not eligible for travel support via the Learner Support Fund are eligible for
 consessionary fare prices. Please contact the Student Welfare Team for an order form.

 SUPPORTING STATEMENT: Please tell us why you need financial support to come to College?




SECTION 6: DECLARATION
 The information I have given on the Learning Support Application form is, to the best of my knowledge, complete and
 accurate. I understand that if I give false information or fail to give complete information, Highbury College may prosecute
 me. I will inform Highbury College immediately of any change in my circumstances that may affect my entitlement to
 assistance from the Learning Support Fund. I understand that any awards are subject to satisfactory attendance and are
 made at the discretion of the Head of Student Support Services. I also accept responsibility for finding out about all other
 sources of financial support available to me prior to my application to the LSF.

                                                  1998 Data Protection Act

 I agree to Highbury College processing personal data contained in this form, or other data which they may obtain from me
 or other people, whilst I am a student. I agree to the processing of such data for any purposes connected with my studies
 or my health, safety and welfare whilst on the premises or for any other legitimate reason. I understand information about
 my entitlement to the LSF may be communicated to teaching or other College staff.


 Signature of Student_____________________ ____________                               Date_______________

 Signature of Parent/Guardian___________________________                              Date________________

 Please note that the Learning Support Fund is available to those studying Further Education at Highbury College. The
 LSF is a discretionary award with a limited budget so early application is recommended. We endeavor to process
 applications within 7-10 working days. If you would like us to return your proof/s of income please enclose a stamped,
 addressed envelope.

 If you have any queries or concerns please drop in to see our Student Welfare Team who are situated at Highbury
 College (Cosham), Highbury City of Portsmouth Centre, Highbury Northarbour Centre, and alternatively, you can e-mail
 us on Welfare@highbury.ac.uk

CHECKLIST FOR STUDENTS
Have you:
Attached proof of household income?                             Have you written your Supporting Statement? 
Attached bank statements for last three months?                 Have you signed your application form? 
Told us what your household expenditure is?                     Have your parent(s)/guardian(s) signed your form? 


                                         PLEASE RETURN THIS FORM TO
                                                Highbury College
                                      Department of Student Support Services
                                               FREEPOST PT332
                                                   Portsmouth
                                                    Hampshire



                                                        Page 4 of 6
             2010/11 LSF CHILDCARE FUNDING
                             APPLICATION FORM

    PLEASE COMPLETE THIS FORM IF YOU WISH TO APPLY FOR
  FINANCIAL HELP TOWARDS YOUR CHILD(REN)’S NURSERY FEES
Student Details
Student’s Name __________________________________________________________________
       Address __________________________________________________________________
               __________________________________________________________________
               __________________________________________________________________
Telephone no(s)_________________________________ _______________________________

Child(ren)’s Details
Name                                                   DOB                 Age on 6th Sept 10
______________________________________                 _________________     ___________
______________________________________                 _________________     ___________
______________________________________                 _________________     ___________

     Please enclose copy of birth certificate for each child requiring funding


Nursery Details
Nursery Name      _______________________________________________________________
Supervisor’s Name _______________________________________________________________
          Address _______________________________________________________________
                  _______________________________________________________________
                  _______________________________________________________________
Telephone no(s) _______________________________________________________________

         Please enclose Nursery’s OfSTED Registration Certificate

Please indicate length of time required (if known)


                         Mon          Tues           Weds       Thurs      Fri
        Start Time



        End Time



                                             Page 2 of 6
 Disclaimer:
I understand that the childcare costs can only be claimed for timetabled College hours, contact classes
(not for private study), ½ an hour before and after the class begins/ends and during Term Time only.

I understand that all childcare providers used must be OfSTED and NEG registered.

I understand that funding for external childcare will only be considered if a place in Highbury’s Nurseries
cannot be secured. I also understand that if a place becomes available at a Highbury
Nursery, I may be asked to take up the space (failure to do so may jeopardize your funding).

I understand that childcare costs are only provided for your dependant children.

I understand that if any circumstances change I must notify the College immediately and that if I fail to
provide proof of income and complete an LSF application, I will be liable for any childcare costs incurred.

I understand no payments will be made until I complete an LSF application and confirmation of approval
is received.

I understand that the contract is between the Registered Child Care Provider and the Student and not
with Highbury College and that Highbury College will not be liable for any disputes that may arise
between the Student and the Registered Child Care Provider.

I understand that Highbury College will only fund a maximum of £3 per hour for the Childcare provided.

I understand that any timetable changes and requests in funding increases must be made in writing and
are not guaranteed.

I understand that Highbury College will not fund “In-Set Days” or any extra days such as sickness,
training, etc.

I give permission to Highbury College staff to liaise with my Child Care Provider regarding invoice
payments and the terms and conditions of the Learner Support Fund.

I understand that I am responsible for ensuring that invoices are received by the Student Welfare Team
by the 5th day of each month. Failure to comply will result in non payment of your childcare. (Please
clearly write your name, your child(ren)’s Name (s), the price per hour, and the total number of hours
used per week.)

I confirm that I am over the age of 19 as of 31/08/10.
__________________________________________________________                               __________
Student Signature                                                    Date
______________________________________________________________________________
CHECKLIST FOR STUDENTS

Have you:
Completed an LSF application form and attached proof of income                       
Enclosed copies of your child (ren)’s birth certificates                             
Enclosed a copy of your childcare provider’s OfSTED Registration Certificate         
Signed your application                                                              
Applied for a Nursery Position (separate application form)                           

                                                 Page 3 of 6

				
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