La Trobe Industry Placement Bursary application Required fields are marked with an asterisk (*). Do you have a confirmed placement listed in InPlace? (Placement commencing between 14 October 2024 and 23 Feb 2025) * Yes No Please contact your Placement Officer to request your placement details in InPlace are reviewed. Once placement is confirmed in InPlace you can return to complete your application form. My detailsGiven name * Family name * Student ID # * Date of Birth * Day 12345678910111213141516171819202122232425262728293031 Month JanFebMarAprMayJuneJulyAugSeptOctNovDec Year 19001901190219031904190519061907190819091910191119121913191419151916191719181919192019211922192319241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045204620472048204920502051205220532054205520562057205820592060206120622063206420652066206720682069207020712072207320742075207620772078207920802081208220832084208520862087208820892090209120922093209420952096209720982099 Email * (This must be your La Trobe student email address - do not use your LTU log-in. If you incorrectly use your LTU log-in, you will not receive correspondence relating to your application from us) Course name * Campus * -- Please Select --Albury-WodongaBendigoMelbourne (Bundoora)Melbourne (City)Mildura SheppartonOnline Scholarship detailsPlease specify the Work Integrated Learning (WIL) or clinical placement subject code you are enrolled in for which you are undertaking the placement. * Ensure this code is the correct code and applies to the current Semester. Including an incorrect code may have an affect on the success of your application. Please indicate the approximate travel time required from your home address to the location of your placement. How do you think the Industry Placement Bursary will reduce your financial hardship while undertaking your placement? * Select one: Completely Substantially Moderately Marginally Not at all How do you plan on using the Industry Placement Bursary to assist with placement expenses? * Forgone income from regular employment Additional accommodation costs Additional carer costs Equipment costs or miscellaneous costs Personal circumstance Are you or will you be the first person in your immediate family to attend university? (immediate family = parents, brothers, and sisters) Yes No Are you of Aboriginal Australian or Torres Strait Islander descent? Yes No Have you ever spent time in formal out-of-home care? (e.g. foster care, residential care, kinship care or been a ward of the state) Yes No Specify the type of care How long were you in formal out-of-home care (months) Do you have a medical condition or disability which impacts your ability to study? Examples of medical conditions and disabilities include but are not limited to: Physical impairment (e.g. blindness), Learning disabilities (e.g. dyslexia), Chronic pain, Eating disorder (e.g. anorexia), Mental illness (e.g. depression), Major illness (e.g. cancer)Applications submitted without medical evidence will not be scored for medical disadvantage. LAPs do not provide enough detail and are not recommended for submission. Yes No Name of condition Duration of condition (months/years) Briefly describe your condition/disability, the impact, timing and how they have adversely affected your education or ability to pursue education. Your personal statement must include the duration and the impact of your condition. (to receive consideration for this criteria, you will be required to provide evidence, see below) Personal statement max 2500 characters You must provide proof of our medical circumstances such as a statement of support from a medical professional You must provide a recent (within 12 months) statement of support from a medical professional who treated or is currently treating your condition(s)/disability. Ensure the contact details of the professional and date is included. Applications submitted without medical evidence will not be scored for medical disadvantage. LAPs do not provide enough detail and are not recommended for submission. PLEASE NOTE: .pdf file type ONLY. Max file size 8MB. Are you or have you been a refugee? Yes No Family circumstance What is your household structure? Live alone Live with flat mates Live with my spouse/partner live with parents/guardians Live in single parent/guardian household Do you have children? Yes, I have children No, I do not have children The number of children less than 16 years of age The number of children 16 years of age or older Parenting I am a sole parent I share custody of children Financial circumstance Has your education been adversely affected by your financial circumstances or do you expect your tertiary education to be adversely affected by your financial circumstances? You will be required to provide evidence Yes No Do you, the applicant, currently receive any Centrelink benefits (e.g. Youth Allowance or health care card)? Yes No Please provide evidence of your current Centrelink benefit(s) such as an Income Statement dated within the last three months or both sides of your current Health Care Card. For information on suitable evidence check our supporting documentation requirements website. (.pdf, .doc, .docx, .jpg or .png file types only. Max file size 8MB) Upload the other side of your current Health Care Card. What is the gross income of your household? Household income includes you, your parents or guardians, or your partner. -- Please Select --$0-20,000$20,000-$30,000$30,000-$40,000$40,000-$50,000$50,000-$60,000$60,000-$70,000$70,000-$80,000$80,000-$90,000$90,000-$100,000$100,000-$110,000$110,000-$120,000$120,000+ How many household members (including yourself) are dependent on the household income selected above? -- Please Select --123456789 or more Please provide evidence of all household income contributors. (e.g. Australian Tax Office Notice of Assessment for 2020-2021, or 3 consecutive pay slips dated within the last 3 months, .pdf, .doc, .docx, .jpg or .png file types only. Max file size 8MB) What percentage of your weekly income is spent on rent/mortgage payments? -- Please Select --0-29%30-50%51-100% Impacts on education Has your education been disadvantaged by difficult circumstances not outlined above? (examples of difficult circumstances may include abusive family circumstances, excessive carer duties, chronic medical condition of a child, death of close relative, homelessness, recent multiple relocations, recent separation of parents, relationship breakdown, victim of crime, bullying.) Yes No Please describe the impact and timing, and how it has adversely affected your education or ability to pursue education. (to receive consideration for this criteria, we require supporting evidence, see below) (max. 250 words) Please provide a statement of support about your difficult circumstances. (This may be in the form of a SEAS Statement, death notice, police report or statement by a relevant responsible person. For example; health care professional, social worker, counsellor, religious or community leader, school principal or teacher etc, unrelated to you as the applicant, who can verify the circumstances. Statements of Support must be recently dated (within 12 months), on letterhead or include contact details of referee. Statement must include duration and impact of the circumstances. *Applicants who do not supply supporting documents will not be scored for difficult circumstances. .pdf, .doc, .docx, .jpg or .png file types only. Max file size 8MB) AcknowledgementI accept that the Industry Placement Bursary is offered and paid on the condition that the recipient maintains enrolment in an approved clinical placement subject or Work Integrated Learning (WIL) experience at LaTrobe University: * Yes No I accept this bursary is not transferable to another institution, under any circumstances: * Yes No I agree it is the recipient's responsibility to contact the Australian Taxation Office (ATO) and Centrelink for advice regarding the taxation and Centrelink payment implications of the bursary: * Yes No Privacy All information provided by applicants will be treated as confidential. At La Trobe University, we respect the privacy of your personal information. We collect personal information in your application to determine your eligibility for a scholarship, bursary or grant, and to assess your application as part of the ranking and allocation process. In accordance with privacy laws, personal information about you contained in your application will not be used for any other purpose or disclosed to any person who is not part of the La Trobe assessment and allocation process, without your permission. You may have the right to access personal information we hold about you, subject to any exceptions in relevant laws, by contacting the Scholarships Office. The La Trobe University privacy policy can be viewed at: www.latrobe.edu.au/privacy Validation
