INDIGENOUS YOUTH LEADERSHIP PROGRAM
APPLICATION FORM
TERTIARY SCHOLARSHIP 2010
(Excluding the Referee Forms, please do not extend to more than 10 pages)
NB In administering the Indigenous Youth Leadership Program, MADALAH Limited will need to collect
personal information from you. This will include the personal information provided on this form and may
also include other personal information collected by the educational institution attended by you if you are
successful with your application. The purpose of this collection is to enable MADALAH LIMITED to
administer the Indigenous Youth Leadership Program and will not be used for other purposes, except as
authorised or required by law.
MADALAH LIMITED is also required to provide some of your personal information contained on this form
to the Department of Education, Employment and Workplace Relations (DEEWR). This will not include
your name but will include some of the personal information contained above. This will be used by
DEEWR for program monitoring and evaluation purposes. DEEWR will not use or disclose your personal
information for any other purpose except as authorised or required by law.
Applicant details – please print in capital letters
Title
Surname
First name
Date of
Birth
Are you Aboriginal?
Age
Yes
No
Male
Are You Torres Strait Islander?
Are you eligible for Abstudy? (If yes, please provide proof of eligibility)
Female
Yes
No
Yes
No
If ineligible, please state if you are disadvantaged in another way
If you receive funding other than Abstudy (ie. Austudy, Isolated Children’s Allowance, Youth
Allowance), please state and provide proof of Aboriginality
Address of usual place of Residence
Postal Address (if different)
Home Phone
Mobile
Work Phone
Fax
Email Address
Page 1 of 13
Local Government/ Home Community/ Town/ Island of Home Residence
Traditional Owners of the Land of Home Community
Do you speak a language other than English?
Aboriginal Language?
Torres Strait Islander Language?
Aboriginal English
Broken English
Torres Strait Creole/ Yumpla Tok
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Please provide language name
Please provide language name
If you are awarded the scholarship, you agree to use the funding for the following purposes. By
ticking the boxes below, you agree to this use of the funding:
 Enrolment and tuition fees
 Text books
 Other essential educational costs
2. Details of Schooling
Name of School you attended
School Location
State
Was your School (please tick)
Government
Catholic
Independent
Year level completed at School
3. Please describe your current living arrangements e.g. are you living in your local community or
are you living in a city area with other family while you attend higher education or are you/ will you board at
the university etc?
Page 2 of 13
4. Name of education institution you are attending or have applied to attend in 2010?
(Please provide evidence of enrolment or acceptance to a higher education course – see note on page 6)
2010 course name
2010 course level
Duration of course
5. What are your career/work goals for the future and how will this course assist you to
meet your goals?
6. What are your future leadership dreams and aspirations?
Page 3 of 13
7. Describe a recent situation where you demonstrated leadership. What did you learn
from this experience?
8. What is an important issue in your community that needs to be addressed? How would
you like to make a positive contribution to addressing this issue in the present or
future? How do you think a good leader would address the issue?
9. Have you received any awards or scholarships or any other significant achievement? If
yes, please list and tell us about what you have learnt from your achievements.
Page 4 of 13
10. Are you involved in any community activities outside study or employment? If yes,
please list.
11. What are your hobbies and interests?
12. Do you have any other sources of financial support? e.g. Centrelink study benefits (including
Abstudy, Youth Allowance or Assistance for Isolated Children), work, parental/partner support etc. If
yes, please list.
Page 5 of 13
13. Have you received a grant in the past from any of the following?
□ The Foundation for Young Australians
□ Indigenous Youth Leadership Program
□ The Queen’s Trust for Young Australians
□ The Australian Youth Foundation
□ Commonwealth Government
□ State Government
□ Other
If yes please detail the source, reason, amount and date.
Please provide written references from two referees (using forms provided) and list their
contact details below:
Written Referee 1
Written Referee 2
Name
Address
State, Post Code
Email Address
Telephone Number
Relationship to
applicant (e.g. teacher,
elder, community
representative, employer,
mentor)
NB. Written references can be forwarded directly from the referee to MADALAH LIMITED; however they
must reach MADALAH LIMITED by the closing date of application. Please note that one referee must be
someone within your local community who is not a relative.
Page 6 of 13
IMPORTANT PLEASE NOTE
IYLP Tertiary students may receive only one tertiary scholarship of up to three years duration, at
a university studying a degree course with a full-time workload and excluding enabling or bridging
year courses.
The IYLP Scholarship is offered for up to three years and each student is required to pass
subjects to ensure that the scholarship will continue the following year.
If you are offered an IYLP scholarship you must be prepared to abide by the conditions outlined in
the guidelines.
Your application WILL NOT BE CONSIDERED if you do not provide the following information:

Proof of Abstudy, Youth Allowance or Assistance for Isolated Children eligibility. If you
are currently ineligible, you must clearly state if you are disadvantaged in another way.

Proof of Aboriginal or Torres Strait Islander descent.

Proof of enrolment or acceptance into a higher education course in 2010 on institution
letterhead. If you are awaiting acceptance into a higher education course in 2010,
MADALAH LIMITED will require confirmation of enrolment and subject listing when this
information becomes available (within 2 weeks of the closing date).

Recent academic results on institution letterhead. (The 2010 scholarships will be
awarded on condition that your 2009 results to date are satisfactory results.)

If you are under 18 years of age, your application requires your parent or caregiver’s
signature

Two written references

Please DO NOT staple or photocopy your application double sided
Checklist (Please tick)

Proof of Abstudy, Youth Allowance or Assistance for Isolated Children eligibility
(documentation from Centrelink is required)







Completed application form
Proof of enrolment or acceptance into a higher education course in 2009
Referees contact details included
Two written references included or
Referees notified of requirement to forward reference to MADALAH LIMITED before
closing date
Academic results for 2009 to date included
Proof of Aboriginal or Torres Strait Islander descent
Page 7 of 13
Signature

Date
Applicant
/ Other
(please
The closing
date is
January
15thspecify)
, 2010. Late or incomplete submissions will not be
considered.

Applications should be no more than 10 pages plus proof of Aboriginal and Torres Strait
Islander descent.

Please attach only TWO references (as per the forms attached).

Please submit only ONE copy of your application by one of the delivery methods listed
below.

Please note that the fax machine becomes very busy on the closing day, therefore
please try to forward your application as soon as possible.

Within seven days of the closing of applications, MADALAH Limited will notify you of
receipt by forwarding an email to the email address provided in your application. If you
do not have an email address, MADALAH Limited will forward a written confirmation
letter to the postal address listed on your application. If you are not notified within seven
days, please contact MADALAH by phone.
APPLICATIONS SHOULD BE SENT TO:
MADALAH LIMITED
PO Box 285
Willetton WA 6955
Email
[email protected]
Fax
(08) 9259 5733
Please direct any enquiries to:
MADALAH Limited
Phone
(07) 9259 5700
[email protected]
www.madalah.com.au
Page 8 of 13
INDIGENOUS YOUTH LEADERSHIP
TERTIARY SCHOLARSHIP 2010
REFERENCE
This reference is to be neatly hand written and should not exceed two pages
Applicant’s Name
Referee’s Name
Street Address
Postal Address (if different)
Phone Work
Fax
Phone Home
Mobile
Email Address
Occupation/ Position
Please answer the following questions
1. How do you know the applicant? (eg. work colleague, employee, student, personal friend)
Page 9 of 13
2. Explain why you believe the applicant should receive an IYLP Tertiary Scholarship.
3. Would you like to receive information about further opportunities offered by MADALAH
LIMITED?
 Yes  No
4. How did you find out about the Indigenous Youth Leadership Program Scholarship for
insert year? (Tick more than one if appropriate)
 MADALAH LIMITED
 Ourcommunity.com
newsletter
 MADALAH LIMITED
 Word of mouth
website
 MADALAH LIMITED
 Koori Mail
email
 MADALAH LIMITED Committee member 
Newspaper
 Mail out
 Tertiary Institution
Signed:
 DEEWR Website
 Email list group eg.Youth Gas
 National Indigenous Times
 Radio
 Other ………………………..
Date:
Please note - receipt of this application at insert email address directly from the referee’s email
address will be read as a signature to the truth of the contents of this document.
Please send to: MADALAH Limited – www.madalah.com.au
By mail
PO Box 285, Willetton, WA 6955
By email
[email protected]
By fax:
(08) 9259 5733
Phone:
(08) 9259 5700
Page 10 of 13
INDIGENOUS YOUTH LEADERSHIP
TERTIARY SCHOLARSHIP 2010
REFERENCE
This reference is to be neatly hand written and should not exceed two pages
Applicant’s Name
Referee’s Name
Street Address
Postal Address (if different)
Phone Work
Fax
Phone Home
Mobile
Email Address
Occupation/ Position
Please answer the following questions
1. How do you know the applicant? (eg. work colleague, employee, student, personal friend)
Page 11 of 13
2. Explain why you believe the applicant should receive an IYLP Tertiary Scholarship.
3. Would you like to receive information about further opportunities offered MADALAH
LIMITED?
 Yes  No
4. How did you find out about the Indigenous Youth Leadership Program Scholarship for
2008? (Tick more than one if appropriate)
 MADALAH LIMITED
 Ourcommunity.com
newsletter
 MADALAH LIMITED
 Word of mouth
website
 MADALAH LIMITED
 Koori Mail
email
 MADALAH LIMITED Committee member 
Newspaper
 Mail out
 Tertiary Institution
Signed:
 DEEWR Website
 Email list group eg.Youth Gas
 National Indigenous Times
 Radio
 Other ………………………..
Date:
Please note: receipt of this application at insert email address directly from the referee’s email
address will be read as a signature to the truth of the contents of this document.
Please send to: MADALAH Limited – www.madalah.com.au
By mail
PO Box 285 Willetton, WA 6955
By email
[email protected]
By fax:
(08) 9259 5733
Phone:
(08) 9259 5700
Page 12 of 13
INDIGENOUS YOUTH LEADERSHIP
TERTIARY SCHOLARSHIP 2010
Parent/Caregiver Permission
To be completed if applicant is under 18 years of age
Applicant’s Name
Parent/Caregiver’s
Name
Street Address
Postal Address (if different)
Phone Work
Fax
Phone Home
Mobile
Email Address
I acknowledge that I understand and support ____________________’s application for an IYLP
Tertiary Scholarship.
Signed: ________________________________ Date: _______________________________
Page 13 of 13