Viola Desmond Bursary Application
Celebrating the Strength of Black Women in Canada
All applications packages must be submitted by 5 p.m. on February 15, 2016.
Section A: Applicant information
Name
Address
City
Postal code
Phone
Cell
Email
I identify as Black, African,
African-Canadian
Yes
/
No
Educational background
Full-time student or part-time student
Degree program name
Certificate program name
Graduation date
What year of study are you currently in?
What is your program of studies?
List all special achievements/honors and
extracurricular activities:
All information provided will remain confidential and will be used only for the selection process
The Annual Viola Desmond Awards are organized by the Black History Awareness Committee. For more
information, visit www.ryerson.ca/violadesmondawards.
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The following must be attached as part of this application:
1.
2.
3.
4.
5.
6.
A completed, signed copy of this application form
An official transcript
A signed FIPPA Statement
One academic reference letter
Character reference letter (non-relative)
Briefly tell us something about yourself in a personal letter (750 words or less).
The Bursary Selection Committee will consider details relating to the following items in the selection
process:





explain why you would be an ideal candidate this Bursary
describe your involvement in school, community, interests / hobbies and your values and
goals
explain why you’d be an ideal candidate to receive this bursary
how you have/will navigate the Canadian Educational System and culture as your pursue
your studies at Ryerson
elaborate on financial need
Section B: Declaration by applicant
I hereby certify that the information provided in this application formation provided herein is complete and
correct.
___________________
Date
__________________________________
Signature of Student
All information provided will remain confidential and will be used only for the selection process
The Annual Viola Desmond Awards are organized by the Black History Awareness Committee. For more
information, visit www.ryerson.ca/violadesmondawards.
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Freedom of Information and Protection of Privacy Act
(FIPPA Statement)
This information is collected under the authority of the Ryerson University Act and is used by Financial
Assistance at Ryerson University for the purposes of determining your eligibility for financial assistance,
including but not limited to financial awards and bursaries. The information collected may also be used on
an aggregate basis in order to comply with Ryerson University’s statutory reporting obligations. The
information you provide will not be disclosed for any other purpose except for as stated herein unless
authorized and/or required by law. If you have questions about the collection, use, and disclosure of this
information by Ryerson University please contact Darrell Bowden, EDI - Education and Awareness
Coordinator in the Office of the Assistant Vice President/Vice Provost Equity, Diversity and Inclusion.
In order to assess your eligibility for some forms of financial assistance, we may need to review your
academic record.
By checking the box below, you hereby consent to the disclosure of your academic record by the Registrar
to Financial Assistance for the purpose of assessing your eligibility for student financial awards and/or
assistance.
Please note that if you do not consent to the disclosure, we will not be able to determine your eligibility for
some forms of financial assistance.
Name
Student number
____
I consent to the disclosure of my academic record by the Registrar to the Office of Equity, Diversity
and Inclusion for the purposes set out above.
____
I do not consent to the disclosure of my academic record by the Registrar to the Office of Equity,
Diversity and Inclusion for the purposes set out above.
___________________
Date
__________________________________
Signature
All information provided will remain confidential and will be used only for the selection process
The Annual Viola Desmond Awards are organized by the Black History Awareness Committee. For more
information, visit www.ryerson.ca/violadesmondawards.
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