Townsend Scholarship Form

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Townsend Scholarship

As a result of the generosity of Lambeth resident Miranda Townsend, each year the Foundation is able to offer up to three scholarships to Lambeth Black and Minority Ethnic pupils from low-income homes who gain a place at a Russell Group University. Each scholarship will be worth £1,000 a term for three years (£9,000 in total).

We would strongly recommend saving your work regularly. If you need to save your work and return to it, please click on link in top right hand corner

Before completing this form please read the guidance notes. Also if you wish to check your financial eligibility, click here. If you wish to see a pdf preview of this form, click here.

First Name	Last Name
Title

ELIGIBILITY QUESTIONNAIRE

Do you currently live in the London Borough of Lambeth and have you lived in Lambeth for at least one year?

If you live outside Lambeth but have been looked after (i.e. in care of) by the London Borough of Lambeth for at least one year, you should answer yes. If you live outside of Lambeth with your family but still in the care of Lambeth (e.g. your family receives housing benefit from Lambeth Council) you should answer yes.

Are you in receipt of Free School Meals OR your family receiving income-based benefits (JSA or ESA or income support)/earning very low wages or without access to state benefits?

Do you (or your family if you are living in the family home) rent your home?

Do you consider yourself to come from a Black or Minority Ethnic background?

Have you accepted an offer from a Russell Group University and be intending to start in the 2016/17 academic year?

If you have answered ‘no’ to any of the questions above you will not be eligible for a grant from us and should not complete this form

Contact Details

Street Address

City

Post Code

Phone

Mobile Phone

Email

Previous Address Details

Only enter this if you have lived at your present address for less than one year

Personal Information

Gender

Ethnicity

Immigration Status

Date of Birth (DD/MM/YY)

Place of Birth

How many Years in Lambeth

Please just write number - e.g. 9, not "9 years" or "Since 2006"

National Insurance Number

How did you hear of us?

Please give name of organisation if appropriate.

Education and Employment Details

Education

From secondary school onwards, please list the schools/colleges you have attended with your current one first with subjects studied. Please give details of any qualifications received (e.g GCSEs) and predicted qualifications for A-Levels

Apart from yourself, how many other people live in your household?

Person 1 - Name

Person 1 - Age

Person 1 - Relationship to Applicant

Person 2 - Name

Person 2 - Age

Person 2 - Relationship to Applicant

Person 3 - Name

Person 3 - Age

Person 3 - Relationship to Applicant

Person 4 - Name

Person 4 - Age

Person 4 - Relationship to Applicant

Person 5 - Name

Person 5 - Age

Person 5 - Relationship to Applicant

Details of all other people not listed above in your household

Please give details (Name, Age, Relationship to you)

Landlord Details

Are you in receipt of Free School Meals?

Is at least one of your parents/carers in receipt of Means Tested Benefits?

FINANCIAL INFORMATION

Please provide this information about the head/s of household. We know that your family will have other expenses in addition to those listed below. However, these are not included in our financial eligibility calculation, so please do not list them. You must complete this section carefully. Without these details we cannot work out whether you are financially eligible for a grant and your application will be returned. All income that you enter in this section should match up with the bank statements that you have provided.

WEEKLY INCOME

Please enter numbers only (no letters or symbols)

Income - Parent's wage

Income - Second parent's wage

Income - Income Support

Income - Pension Credit

Income - Job Seekers Allowance

Income - Employment Support Allowance

Income - Universal Credit

Income - Child Benefit

Income - Child Tax Credit

Income - Working Tax Credit

Income - Child Support Payments

Income - Bursary (e.g. 16-19 Bursary Fund or NHS Bursary)

Income - Student Loan

Income - Student Grant

Income - DLA/PIP

Income - Attendance/Carers Allowance

Income - Other

Income - Other - Details

Weekly Income Total

WEEKLY EXPENDITURE/OUTGOINGS

Please enter numbers only (no letters or symbols)

Expenditure - Rent (excluding arrears)

Amount that you pay DIRECTLY

Expenditure - Council Tax (excluding arrears)

Amount that you pay DIRECTLY

Expenditure - Service Charge (excluding arrears)

Expenditure - Water Rates (excluding arrears)

Expenditure - Gas/Electricity (excluding arrears)

Expenditure - Childcare

Expenditure - Childcare - Details

If you have listed childcare costs above, please break them down here (i.e. number of hours/days per week; cost per hour/day - PLEASE NOTE - this is for EXISTING childcare costs that you are CURRENTLY paying for

Expenditure - Fares (to work)

Expenditure - School lunches

Expenditure - Prescriptions

Expenditure - Disability expenses

Expenditure - Disability/Care related expenses - Details

Weekly Expenditure Total

Course Details

Course Name

University Name

Course Start Date (DD/MM/YY)

Course End Date (DD/MM/YY)

Course Entry Requirements

Course Expected Qualifications

Your Grant Request

Why are you applying for your chosen course?

Please explain why this course interests you. Are there subjects within the course that you are interested in focusing on? Also, if appropriate, please indicate any particular reasons on your choice of university.

What are your long term career goals?

In this section, please give details about what job you would ultimately like to have. Please also sketch out what steps you think you will need to take to reach this career goal. It will also be important to highlight how your chosen university/course will assist you in this.

What relevant skills, experience or achievements have you gained from education, work (paid/voluntary) or other activities and how do you think these experiences will help you at university?

This section enables you to give details about experiences and achievements that highlight particular skills that will benefit you to make the most of your time at university. Examples are: volunteering at a local community project, position of responsibility in a sports team or after-school activity, school prize, Saturday job etc. Please make the experiences and achievements as specific as possible and explain how these have helped you develop particular skills/attitudes.

How will the Miranda Townsend Scholarship enable you to make the most of your time at university?

Please give details of how the additional funds would help you at university. You can give information about how it could be used towards such items as general living costs (e.g. rent, food), travel costs, IT equipment, specialist equipment/software, support with extra-curricular activities (e.g. sport, music) or opportunities during the holidays to gain experience that would benefit your course/career plans.

REFEREES

Ref1-Title

Ref1-FirstName

Ref1-Surname

Ref1-Relationship

This referee should be your current tutor.

Ref1-Address

Ref1-Email

Ref1-Telephone

Ref2-Title

Ref2-FirstName

Ref2-Surname

Ref2-Address

Ref2-Relationship

Ref2-Email

Ref2-Telephone

PAYMENT DETAILS

Payee Account Name (e.g. John Smith)

Length of Payee Name should be 18 characters max. Letters/Numbers only - no special characters

Account Number

Sort Code

Bank Name

Additional Documentation

If there are problems with attachments, you can send the documents to Walcot Foundation, 127 Kennington Road, London SE11 6SF or email to grants@walcotfoundation.org.uk. Please note that the maximum size of each file is 5MB.

Confirmation of your identity, such as a copy of your birth certificate, medical card, passport or similar document

Sending by post

Proof of one year's residence in Lambeth, such as a copy of a utility bill or tenancy agreement that is more than one year old. If you are not living in Lambeth but are in care to Lambeth, please provide a housing office letter or similar on official letterhead confirming that you have at least one year's connection to Lambeth.

Sending by post

Copy of your offer letter from a Russell Group university

Sending by post

Proof of low income. This should be a) Signed letter from school confirming that you are in receipt of Free School Meals OR b) Copy of means tested benefits letter from parent dated within last two months OR c) copies of the last two bank statements for the head(s) of household. For all benefits, tax credits and wages that you and the head(s) of household receive, we must see the last two bank statements of the accounts these are paid into. On the copies of the last two bank statements (again, all current and savings accounts), we ask that your parent/carer make notes against entries to explain the source of incoming funds if they are not already clearly marked (for example, deposits and bank transfers).

Sending by post

Your Bank Statement: We need a copy of a recent bank statement for the bank account that the grant would be paid into. This should be in your name.

Sending by post

Any other documentation you wish to submit that you feel is relevant to your application.

Please send any hard copies to:

The Grants Team
The Walcot Foundation
127 Kennington Road
London
SE11 6SF

Please ensure that you include a covering letter so that we can match your documents with this application.

DECLARATION (updated 3/5/18)

I certify that the information that I have given in this application is true and complete. (Please note that a decision will be based on the information given on this form. If a grant is awarded and the information is subsequently found to be incorrect, any grant that had been awarded could be withdrawn and you could be asked to repay any monies already paid.)

I agree that information I have given may be discussed with representatives of my college/university, my referees and my current school.

To help the Foundation monitor and evaluate its work, I agree I may be contacted in the future.

I confirm I have contacted Student Finance and in the process of applying for any financial assistance for which I might be eligible.

I agree that any grant awarded will not be used toward purchases already made or debts.

I have read the application's guidelines in full.

I have no objection to the data contained in this application being held by the Walcot Foundation for the purpose of considering this grant application. For more information on how we handle your personal information, please see our Privacy Policy.

If awarded a grant, I agree to provide a written report each year on the impact of the Townsend Scholarship grant.

AGREEMENT

I agree to the Declaration above

OPTIONAL

I agree that Walcot Foundation may share non-grant information with me that the Walcot Foundation considers may be useful (e.g. Walcot e-newsletter, details on training and other grant programmes etc)

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YOU ARE NOT ELIGIBLE FOR A WALCOT FOUNDATION GRANT

You have entered "No" on one of the eligibility criteria and so are not eligible for a grant. You may find other grants on http://www.turn2us.org.uk/.