UCD ACCESS & LIFELONG LEARNING
FUTURE YOU SCHOLARSHIPS 2016
Please return completed application form and all supporting documentation to:
Future You Scholarships, UCD Access & Lifelong Learning Centre,
Attn: Margaret MacDonagh, Level 1, JJL Building UCD, Belfield, Dublin 4
Notes on completing
the application
form:
Future
You Scholarships
Part A:
2013
General information
Making
an Application
1. Please ensure you
have completed
all the relevant sections. The application form
will be used to shortlist candidates, therefore it is important to provide as much
relevant information as possible. Incomplete applications cannot be considered.
2. All sections must be completed by the applicant unless otherwise stated. A
Guidance Counsellor/Year Head/teacher from your school should complete and
sign page 3 and page 11. Both applicant and parent/guardian must sign on page
10. (The only exception to this is for applicants in care of TUSLA who can just sign
page 10 themselves)
3. Applicants in care of TUSLA do not have to complete page 6.
4. Page 9 refers only to applicants in care of TUSLA. If you are in care of TUSLA,
please read this page carefully to understand the information/documentation
required from you.
5. Your completed application form along with all financial documentation must be
returned by post to Future You Scholarships, UCD Access & Lifelong Learning,
Attn: Margaret MacDonagh, Level 1, James Joyce Library Building, UCD,
Belfield, Dublin 4 to arrive by Friday, 1st July 2016.
6. Applicants should retain a certificate of postage.
7. Late applications will not be accepted.
Part B:
Guidance Counsellor/Year Head/teacher reference
A reference from a Guidance Counsellor, Year Head or teacher from your school is
required on page 11 of this application form. The reference must be signed and
dated by them.
PLEASE RETAIN THIS PAGE FOR YOUR OWN INFORMATION AND KEY DATES
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UCD ACCESS & LIFELONG LEARNING
FUTURE YOU SCHOLARSHIPS 2016
Part A – General application form
Section 1 – General information
1.1 Candidate information
Surname:
(as on CAO form)
Date of birth:
First name(s):
(as on CAO form)
DD/MM/YYYY
Nationality:
CAO number
Country of birth:
Gender:
1
Male
Female
6
Home address:
Home phone:
(must be filled in)
Mobile phone:
E-mail:
What UCD courses have you applied for? (Please give name of course and course code)
Course name
Code
DN
DN
DN
DN
DN
Course name
2
Code
DN
DN
DN
DN
DN
1.2
Guidance Counsellor details
(To be completed and signed by the Guidance Counsellor from your school )
Name:
Job Title:
Telephone:
Fax:
E-mail:
How long have you known the applicant?
To the best of your knowledge is the applicant normally Yes
resident at the stated address on page 2? (please tick
one)
Signature:
No
Date:
Section 2 – Educational history
2.1 Second-level education
Dates of Attendance
School(s) attended
From
To
2.2 Have you made an application to UCD under the Higher Education Access Route (HEAR) or the
Disability Access Route to Education (DARE)?
HEAR
Yes
No
DARE
Yes
No
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2. 3 Academic record
Applicants must provide details of their Junior Certificate, listing their subjects, including subject level and grade
obtained. Applicants who have not yet sat the Leaving Certificate must provide details of subjects they will be
taking, including level and a predicted grade. A Guidance Counsellor, Year Head or teacher from your school may
complete this page of the form. Predicted results for the Leaving Certificate MUST be verified with an official
school stamp.
Junior Certificate
Predicted Leaving Certificate results for 2016
Year:
Subject Level of Exam Grade or
(H/O/F)
Mark
Subject
Level of Exam Predicted Grade or Mark
(H/O/F)
GUIDANCE COUNSELLOR/ YEAR
HEAD/TEACHER
Print school stamp here
Please print school stamp to verify
Leaving Cert. predicted grades
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Section 3 – Applicant’s personal statement
Please outline (in 250-500 words) a supporting statement as to why you are seeking a Future You Scholarship
and how receiving it would benefit you. Include any details not previously mentioned that you believe will
support your application. We suggest that your statement should include some or all of the following:
1.
2.
3.
4.
5.
The reasons why you wish to study at UCD.
The obstacles that you have faced to date in your educational career and how you have overcome them.
Your personal strengths and experiences you believe will help you to enjoy and succeed at university.
Details about the support and assistance you think you may need while studying at UCD.
Details of achievements and responsibilities you have e.g. involvement in clubs and societies, voluntary
organisations, sport, academic pursuits etc.
6. Your social, sporting and other interest and activities.
Finally please ensure that the content of your statement is legible and typed where possible
Applicant’s personal statement (continued)
5
4.3 PARTICULARS OF INCOME
If parent(s)/guardian(s) currently have more than one source of income, please list all incomes and amounts
received for the year ended 31st December 2015
Total income for the year ended 31st
December 2015
Please insert the relevant amount below.
Mother
Father
Guardian
Documents Required*
Income from employment
(E.g. PAYE – salary, wages, fees,
etc).
P21 for 2015
Income from self-employment
Notice of Assessment for
2014
Payments from the Department of
Social Protection :
Social Welfare statement,
P21 if applicable
Please tick the relevant payment:
Unemployment Benefit: 
Unemployment Assistance: 
Widows Pension: 
Deserted Wives: 
One Parent Family Payment: 
Family Income Supplement: 
Disability Benefit: 
Disability Allowance: 
DSP – Pension Payment 
Please give details: _____________________
Other DSP payment: 
Please give details: _____________________
*Please do not submit original documents as they will not be returned. Send good quality photocopies
including front and back of all pages.
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Section 4 - Financial documentation required in support of application
The following financial documents relating to income must be submitted with your application form:

Dependent applicants must submit their parent(s)/guardian(s) financial documents.
Please apply early for the relevant documents as it can take a number of weeks to receive them
A.
P.A.Y.E employees*:
Copy of Form P60 from employer(s)/pension source for year ended 31st December 2015 (issued by
employers each year) or a copy of P45 if employment has ceased
AND
Copy of Form P21 for the year ended 31st December 2015 (from the Office of the Revenue
Commissioners)
B.
Self-employed*:
Copy of Notice of Assessment in respect of the year ended 31st December 2014
AND, if applicable
If exempt from filing a Return of Income for the year ended 31st December 2015, it will be necessary to submit a
current letter from the Office of the Revenue Commissioners confirming same
C.
Social Welfare recipient*:
A statement of payment(s) from your local Social Welfare office showing the total amounts received for the
year ended 31st December 2014
AND
Copy of Form P21 for the year ended 31st December 2015, if applicable (available from the Office of the
Revenue Commissioners).
Please submit any other financial documentation which you believe will assist in determining
your eligibility for a Future You Scholarship
*PAYE stands for Pay As You Earn. The PAYE system is a method of tax deduction under which a person’s employer calculates the tax due and deducts it
each time a payment of wages, salary, etc. is made to an employee. Please see www.revenue.ie for more details.
*Self-employed people are those who are in receipt of income from sources which are not chargeable to tax under the PAYE system, or where some, but not all
of their tax on these sources of income is paid under PAYE. Please see www.revenue.ie for more details.
*Social welfare recipients are those who receive financial assistance from government sources.
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Section 4 – Barriers to progression - Financial Details

SECTION 4 TO BE COMPLETED BY THE PARENT(S)/GUARDIAN(S) OF THE APPLICANT

APPLICANTS WHO ARE IN THE CARE OF TUSLA DO NOT HAVE TO COMPLETE THIS PAGE
4.1 DETAILS OF DEPENDENT CHILDREN
Please give details of the number of dependent children (including foster children) under the age of
sixteen on January 1st 2016, or over sixteen years attending a full-time course of study at an
educational institution or medically certified as permanently unfit for work.
Name
Date of birth
(dd/mm/yy)
Relationship to
applicant
Highest level of education
achieved to date
Current/most recent
occupation or current
place of study
.
4.2 PLACE OF RESIDENCE Please tick the appropriate box
Home Owner
Private Rented Accommodation
Local Authority Tenant Purchase Scheme
Local Authority rented flat
Local Authority rented housing
Other non-permanent accommodation
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This page is for the attention of applicants who are in
Care of the State/ HSE/ TUSLA only*
(*Please see notes on page 10 relating to this section)
If you are a foster/separated child or in the care of the HSE / TUSLA (the Child and Family
Agency) you must:
Supply a letter from TUSLA detailing:
 Date you were taken into the care of TUSLA / the HSE
AND
 The amount of income and/or type of support TUSLA provided to you/your foster
family in the year ending 31st December 2015
UCD Access & Lifelong Learning Centre
Future You Scholarships
Level 1, JJL Building
UCD, Belfield, Dublin 4
1st June 2016
Applicant:
CAO number:
PPS Number:
To Whom It May Concern:
(name of Scholarship applicant) is currently in the care of TUSLA / the HSE and has
been since
TUSLA provided the following supports for the above applicant for the year ending
31st December 2015;
€
(Total amount of financial support)
Please list any other TUSLA supports this applicant receives;
Kind regards,
Name of Social Worker/Project Worker
Position in TUSLA/ the HSE
Contact Telephone number
Contact e-mail address
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Notes relating to Page 9:

The letter you provide must be on TUSLA stationery.

A separated child is any child under 18 years of age who is outside his/her country of origin and
separated from both parents or his /her legal/ customary primary caregiver.

A foster child is any child who is looked after by someone else other than the parents, by an order of
the court or TUSLA, without a formal adoption.

You can get this letter from your TUSLA Social Worker or Project Worker.

To contact TUSLA you can e-mail info@tusla.ie or telephone 01 771 8500
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Section 5 - Other barriers to progression
TO BE COMPLETED BY ALL APPLICANTS
5.1 Financial barriers
What family or personal circumstances impact on your financial situation?
5.2 Disability
For applicants with a disability, please outline the nature of the disability, any special requirements and financial
implications arising in relation to pursuing educational opportunities.
5.3 Other Grants, Awards, Bursaries, Scholarships, Financial Supports (public and private)
Have you applied for any other scholarships/bursaries/awards?
Yes
No
If “Yes” please give details:
Declaration
Please note that this declaration has to be signed by both the applicant and a parent/guardian (except for applicants in care of TUSLA who do
not have to provide a parent/guardian signature)
I/we certify that the information supplied on the application form is correct and complete. I agree that UCD may check my CAO course
choices and CAO Change of Mind as necessary to process this application
Signature of parent/guardian: _________________________
Date: _____________________________
Signature of applicant: ______________________________
Date: _____________________________
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Part B - To be completed by Guidance Counsellor/Year Head/ teacher
Personal reference (200 - 400 words)
Guidance Counsellor/Year Head/teacher - please provide/attach a written reference to
support the candidate’s application.



Outline why you are supporting this candidate and why you believe s/he deserves to
be awarded a Future You Scholarship based on the selection criteria (please refer to
scholarship information guidelines).
Comment on the candidate’s academic record, in terms of the likelihood of their
meeting the entry requirements for their desired course in UCD.
Outline your knowledge of the barriers to participation in education that the candidate
has overcome or is currently experiencing. Please provide as much relevant
information as possible.
Referee’s signature: _______________________________ Date: _____________
The University is subject to the Freedom of Information Act 1997 with effect from the 1st October 2001. Therefore you should
note that UCD may under this Act, be under an obligation in certain circumstances to divulge or grant access to information and
records which are contained in references or which are otherwise acquired in the course of the Higher Education Access
Route. The university will in all instances be bound by the findings of the information Commissioner with regard to any requests
under the Act
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Application form checklist
In order for your application form to be accepted, please ensure that you:
Have completed the application form in full and included your 2016 CAO number
Have asked your Guidance Counsellor/Year Head/teacher to verify predicted results with school stamp
Have attached all the required financial documents (see summary below)
Have included Part B - completed personal reference in support of your application
Have signed the form along with parent (where applicable) and referee
Summary of financial documents required
A.
P.A.Y.E employees*:
Copy of Form P60 from employer(s)/pension source for year ended 31st December 2015 (issued by
employers each year) or a copy of P45 if employment has ceased
AND
Copy of Form P21 for the year ended 31st December 2015 (from the Office of the Revenue
Commissioners)
B.
Self-employed*:
Copy of Notice of Assessment in respect of the year ended 31st December 2014
AND, if applicable
If exempt from filing a Return of Income for the year ended 31st December 2015, it will be necessary to
submit a current letter from the Office of the Revenue Commissioners confirming same
C.
Social Welfare recipient*:
A statement of payment(s) from your local Social Welfare office showing the total amounts received for the
year ended 31st December 2015
AND
Copy of Form P21 for the year ended 31st December 2015, if applicable (available from the Office of the
Revenue Commissioners).
Please submit any other financial documentation which you believe will assist in determining
your eligibility
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