The Clutha Foundation Health Services Scholarship Application

The Clutha Foundation Health Services Scholarship Application

Complete the scholarship application using the questions from the provided DOCX. Preserve the original wording and section order as closely as possible.
Applicant Information
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Mobile Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Occupation
Residency in Clutha District
Citizenship or Residency Status
Course and Discipline Eligibility
Year of Study Eligibility
Education History
Tertiary School/Institution
Tertiary Course details, certificates and qualifications achieved
Tertiary Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Tertiary Finished

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary School/Institution
Secondary Course details, certificates and qualifications achieved
Secondary Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Secondary Finished

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other School/Institution
Other Course details, certificates and qualifications achieved
Other Started

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other Finished

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Current Study Details
Name of Tertiary Institution
Course or Qualification
Year of Study as at 2027
Total Planned Years of Study
Course Start Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Funding, Employment, Interests, and Goals
Bursaries, awards, grants applied for or received in the last two years
Course fees and how you intend to pay them
Employment history
Interests, hobbies, and sports
Community service or volunteering
Leadership and representative roles in the past five years
Where do you see yourself on completion of the course?
Long-term career goals and ambitions
What would receiving this scholarship mean to you?
Any other information helpful for assessment
Referees

At least one of these referees must be domiciled in the Clutha District
Referee 1 Name

First NameMiddle NameLast Name
Referee 1 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referee 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referee 1 Relationship to Applicant
Referee 1 Years Known
Referee 2 Name

First NameMiddle NameLast Name
Referee 2 Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Referee 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Referee 2 Relationship to Applicant
Referee 2 Years Known
Checklist and Declaration
Checklist confirmations
Privacy acknowledgement
Applicant Name

First NameMiddle NameLast Name
Applicant Signature
Declaration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Declaration statement
Document attachment confirmation
Application readiness
Referee acknowledgement
Bank details confirmation
Should be Empty:

The Clutha Foundation Health Services Scholarship Application

Applicant Information

Education History

Current Study Details

Funding, Employment, Interests, and Goals

Referees

Checklist and Declaration