U.C.D. STUDENT WELFARE FUND
Application Form
PERSONAL DETAILS
College/School:
Academic Year:
Programme:
Student Name:
Student Number:
Home Address:
Country of Birth:
Duration of Course:
Term Address (if different)
Part-time:
Telephone:
Full-time
e-mail address:
Mobile Phone:
Age:
Ο over 25
Ο 23 – 25
Ο Under 23
Gender:
Ο Male:
Ο Female:
1
CAUSE(S) OF FINANCIAL DIFFICULTY (note 1)
Ο
Ο
Ο
Ο
Ο
Ο
Ο Other – specify_____________________________________
Bereavement
Illness
Accidents
Unforseen parental unemployment
Family Breakdown
Students who have family obligations
(particularly child care
costs)
______________________________________
PURPOSE OF FINANCIAL ASSISTANCE
Ο Rent/Contribution to home
Ο Lighting/Heating/Power
Ο Travel of an urgent or essential nature
Ο Books
Ο Medical -
Ο Class materials
Ο Doctor
Ο Compulsory Study Abroad
Ο Dental
Ο Food
Ο Other
Ο Other (Specify)
(note 2)
2
FUNDING FROM OTHER SOURCES:
Are you receiving/applied for any other U.C.D. funding?
Ο Yes
Ο No
* If yes, please give details
PRE-TRAINING STATUS
Ο Full time education
Ο Long-term unemployed (more than 12 months)
Ο Unemployed (less than 12 months)
Ο Employed (prior to commencing training)
Ο Not available for employment (more than 12 months)
Ο Not available for employment (less than 12 months)
PRE-TRAINING QUALIFICATION
Ο No qualification
Ο Group Certificate
Ο Intermediate/Junior Certificate
Ο Leaving Certificate
Ο Third Level qualifications – specify
3
Monthly Budget
Income
Monthly
Amount
Expenditure
Monthly
Amount
€
Higher Education Grant
€
Rent/Contribution to home
(annual amount divided by 9)
Scholarship/Bursary, etc
Food
(annual amount divided by 9)
Contribution from Parents/
Light/heat/power
Spouse/Partner/other
Social Welfare payment
Travel of an essential nature
Crèche/child minding
Health Board payment
Books and other
academic materials
Savings
Medical - doctor
-
dentist
-
other (specify)
Employment
Compulsory study abroad
Other, give details
Other, give details
Total Monthly Income
Total Monthly Expenditure
Shortfall
4
U.C.D. STUDENT WELFARE FUND
Year
Official Receipt
I acknowledge receipt of €
awarded by the Student Welfare Fund
Committee as detailed below:Details:
Note: In accordance with EU (ESF) requirements I undertake to provide
receipts to the Committee in respect of the above funding.
Student Name: (block capitals) ………………………………..
Student Signature:
Student Number:
Date: ………………………….
“The Student Assistance Fund is funded by the Department of
Education and Science under the National Development Plan 2000 –
2006, with assistance from the European Social Fund.”
For Office use only
Funding Source
Ο ESF
Ο Private Sources
5