APPLICATION FOR THE
QUEENSLAND ACADEMIES
ISOLATED STUDENT
BURSARY
THIS APPLICATION FORM IS TO BE COMPLETED AFTER READING THE
Queensland Academies Isolated Student (QAIS) Bursary — Information Guide 2017
DEPARTMENT OF EDUCATION AND TRAINING
QUEENSLAND ACADEMIES
ISOLATED STUDENT BURSARY
APPLICATION FORM 2017
TO BE ELIGIBLE FOR THE BURSARY THE FOLLOWING CONDITIONS MUST
BE MET:

the student must not be eligible to receive assistance through the Living Away
From Home Allowances Scheme (LAFHAS); and

the student must have a permanent home address in Queensland; and

the Queensland Government school (with the appropriate year level) closest to
the home address of the student must be located in a Rural or Remote
Education Zone; and

the student must need to travel for at least three hours per day to reach the
Queensland Academy they are attending, using a school transport or public
transport service; and

the student must have satisfactory conduct, progress and attendance at the
Academy.
Privacy notice:
This form collects personal information pursuant to Chapter 13, Part 2 Section 368 of the Education (General Provisions) Act 2006.
The purpose of the collection is to process applications for the Queensland Academies Isolated Student (QAIS) Bursary.
The information collected may be disclosed to the Department of Transport and Main Roads to conduct distance checks.
Relevant information collected is provided to schools attended.
The information may also be provided to Centrelink as required to clarify LAFHAS/AIC entitlements.
Personal information collected by the Department is handled in accordance with the Information Privacy Act 2009.
ISOLATED STUDENT BURSARY APPLICATION
Page 2 of 4
Applicant’s Details (Parent, guardian or carer of the student)
1.
Title
2.
Family Name
3.
Given Name/s
4.
Have you been, or are you currently, known by another
name? If yes, please provide details of this name.
5.
Date of Birth
6(a).
Have you submitted a LAFHAS application for 2017?
Mr
Mrs
Miss
Ms
Other: ____
_______/_______/_______
Yes – go to Question 6(b).
No – go to Question 7.
Yes – you are not eligible for assistance in 2017 through
6(b).
Has your 2017 application for LAFHAS been approved?
the Queensland Academies Isolated Students Bursary.
No – continue to Question 7.
Applicant’s Postal Address (All correspondence will go to this address)
7.
Property Name
8.
Street Address, PO Box or Mail Service
9.
Town/Suburb
10.
Postcode
Student’s Permanent Home Address
11.
12.
Property Name
Number and Street Name
Please include rural address number if available
13.
Town/Suburb
14.
Postcode
Applicant’s Contact Details
15.
Home Telephone
16.
Work Telephone
17.
Mobile
18.
Fax
19.
Email
ISOLATED STUDENT BURSARY APPLICATION
Page 3 of 4
Student’s Homestay Address
20.
Number and Street Name
21.
Town/Suburb
22.
Postcode
Relationship to the Student
23.
What is your relationship with the student?
Father
Mother
Guardian/Carer
Student Details
24.
Family Name
25.
Given Name/s
26.
Has the student been, or is the student currently,
known by another name? If yes, please provide details.
27.
Date of Birth
28.
Gender
_______/_______/_______
Yes – you are not eligible for assistance in 2017 through
29.
Is the student to receive a Commonwealth Indigenous
allowance (ABSTUDY) in 2017?
the Queensland Academies Isolated Students Bursary.
No – continue to Question 30.
School Details
30.
Nearest Queensland Government School that offers
the student’s current Year Level
31.
Address of the school
32.
Year Level enrolled at the Academy
33.
Which Academy is the student attending (please tick)
Year 10
Year 11
Year 12
Queensland Academy for Creative Industries (Kelvin Grove)
Queensland Academy for Health Sciences (Gold Coast)
Queensland Academy for Science, Mathematics and Technology (Toowong)
34.
Distance from the student’s home to the Homestay
Km
35.
Distance from the student’s home to the Academy
Km
ISOLATED STUDENT BURSARY APPLICATION
Page 4 of 4
Personal Account Details
Please provide YOUR financial institution account details for payment of the Queensland Academies Isolated Students Bursary. If eligible for
the bursary, all payments will be made directly to your bank account.
Account Holder 1
Account Holder 2
Type of Account (card, savings, cheque etc.)
Name of Bank
Branch where account is held (Town)
—
Branch Number (BSB)
Account Number
Applicant Declaration
I declare that the information provided in this application is true and correct to the best of my knowledge and belief.
Signature of Applicant……………………………………………………………………………………….. Date………../………../………..
Note:
A person who makes false or misleading statements may, by virtue of the Education (General Provisions) Act 2006 be liable to a penalty.
Privacy Notice:
This form collects personal information pursuant to Chapter 13, Part 2 Section 368 of the Education (General Provisions) Act 2006.
The purpose of the collection is to process applications for the Queensland Academies Isolated Student (QAIS) Bursary.
The information collected may be disclosed to the Department of Transport and Main Roads to conduct distance checks.
Relevant information collected is provided to schools attended.
The information may also be provided to Centrelink as required to clarify LAFHAS/AIC entitlements.
Personal information collected by the Department is handled in accordance with the Information Privacy Act 2009.
PLEASE POST THE COMPLETED APPLICATION TO:
Scholarships and Grants Team
Organisational Transformation, Human Resources
Department of Education and Training
PO Box 15033
CITY EAST, QLD 4002
OR EMAIL THE COMPLETED APPLICATION TO:
[email protected]
APPLICATIONS CLOSE FRIDAY 12TH OF MAY 2017