Office use only:
Date received:
Section 1
Forename/s
Surname
Contact Address
Telephone number
Email address
Date of birth
How did you hear about the Bursary
Award?
Section 2
Are you (Please tick)
Male
Female
1

Section 3
Are you at the time of applying (please tick)
Prospective student
(with offer of university place)
First year
Part I
Second
Year Part I
Third year
Part I
Part II studies
Other
(please state)
Section 4
University
Title of degree course
University registration number
Academic reference submitted with application form
(Yes/No)
Are you the first member of your family to attend University?
2

Section 5
Evidence of financial hardship
Candidates must describe their circumstances in the space below. Any other evidence that helps demonstrate hardship must be presented separately to the proposal and limited to one side of A4. More information is available in the Application Guidance.
3

Section 6
Personal statement
Candidates must explain clearly in the space below why the awards panel should consider them for a learning grant. We would like to know how it will benefit the candidate’s studies and help them to progress in their chosen discipline during the 2015-2016 academic year.
4

Section 7
Income and Expenditure
Please list all your income sources below (including benefits, part time employment and monies received).
Please note: Travel costs are from home to campus or placement only. If travelling by car, please estimate the distance.
Course expenses include field trips expenses, books and equipment.
Income Per
Week
Per
Month
Expenditure Per
Week
Per Month
Student
Childcare Grant
Rent/Mortgage
Endowment Insurance
Building Insurance
Other Insurance
Council Tax Lone Parents
Grant
Parental
Contribution
Bursary
Net Wages
Child Benefit
Income Support
Housing Benefit
Other Benefits
(Please specify)
Maintenance from ex partner
Bank Loans
Water Rates
Food/Household
Gas/Electric/Telephone
Travel Costs
Course Expenses
Tuition Fees (If self paid)
Child care costs related to your course
Disability related costs
Medical Expenses
(Please specify)
Loan repayments
Others (Please specify)
Savings
Sponsorship/Trust
Others (Please specify)
Total
5

Section 8
Ethnic Origin/Age – How would you describe your ethnic origin?
White
British
Irish
[ ]
[ ]
Other White [ ]
Black British
Asian/Asian British
Indian [ ]
Pakistani [ ]
Bangladeshi [ ]
Other Asian [ ]
[ ]
Mixed
White & Black Caribbean [ ]
White & Black African [ ]
White & Asian [ ]
Mixed/Other [ ]
Other Ethnic Group [ ]
Black Caribbean
Black African
Age range
16-24 ( ) 25-40 ( )
[ ]
[ ]
41-54 ( )
Chinese
Eastern European
Prefer not to say
55-65 ( ) 66+ ( )
[ ]
[ ]
[ ]
Section 9
Data Protection Act 1998
The Stephen Lawrence Charitable Trust processes data in accordance with the Data Protection Act 1998.
The personal information that you provide on these forms will be processed for purposes connected to the legitimate business of the Trust and may be transferred between Trust departments. Some of the information that you provide on this form may e sent to the Funding Councils, their agents and other statutory bodies for statistical and other purposes.
Declaration
I declare that the details given on this form are true to the best of my knowledge
Signed:
Please send your application to:
Rosemary Rich
Programme Officer
The Stephen Lawrence Centre
39 Brookmill Road
London
SE8 4HU
Date:
Email: rosemary@stephenlawrence.org.uk
st
6