GREG VICKERY SCHOLARSHIP
APPLICATION FORM
Section 1: Applicant Details
Volunteer / Member
Name:
Status:
Volunteer
Member
Location:
Length of service
with Red Cross:
Email:
Phone Number:
Mobile:
Referees
Referee Details:
Referee Details:
Name:
Name:
Contact Number :
Contact Number :
Staff Member
Name:
Position:
Location:
Length of service
with Red Cross:
Email:
Phone Number:
Mobile:
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Document number:
Authorised by: David Ham
Date: 28/07/2017
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Referees
Referee Details:
Referee Details:
Name:
Name:
Contact Number :
Contact Number :
All applications must include details of both the volunteer/member and staff member
who are submitting the joint application.
Section 2: Program of Activity am of Activity
Provide a description of the program of activity you are planning to undertake (200 words or less)
Please identify other stakeholders who may need to be involved in this program of activity. For
example, stakeholders from another Red Cross National Society
How does this program of activity have a direct and practical application to Australian Red Cross?
To what extent does the program of activity further the Red Cross vision, mission and strategic goals
outlined in Strategy 2015?
How will you ensure a collaborative approach is undertaken during this program of activity?
Section 3: Confirmation
I confirm that this application has been endorsed by my manager and by a National Leadership Team
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Document number:
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Date: 28/07/2017
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member
Volunteer / Member
Staff member
I confirm I have the capacity to jointly undertake the proposed program of activity and achieve the
stated goals
Volunteer / Member
Staff member
I confirm I have not received the Persia Porter Scholarship for activities involving International Travel
within the last 5 years (volunteers, members and staff of NSW only)
Volunteer / Member
Staff member
Section 4: Signatures
Volunteer / Member
Staff member
NLT member
Signature: ...................................
Signature: ....................................
Signature: ...................................
Date:
Date:
Date:
/
/
/
/
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This is an uncontrolled document – please access the intranet for the current version
Document number:
Authorised by: David Ham
Date: 28/07/2017
page 3 of 3