Access to Learning Fund (Hardship) APPLICATION FORM 2017-2018 FOR FULL AND PART TIME STUDENTS PLEASE USE THE GUIDANCE TO ASSIST YOU IN COMPLETING THIS FORM. The information we require is required to process this application. The information is processed internally and is not disclosed to external bodies unless there is a legal requirement. Where appropriate, personal data may be shared with other University Departments. Where requested, sensitive personal data e.g. ethnicity, disability, is only used for statistical or monitoring purposes. We may also contact individual students from time to time to help us with our research and to gather feedback. Where you disclose further sensitive personal data, e.g. health, religion, this information will be used solely in the eligibility assessment and will not be disclosed further. Application forms and documentation will be kept securely and stored for up to five years after your last contact with the Service. Some personal data, e.g. name, contact details, programme of study and decision on application is also stored electronically and securely for up to five years after last contact with the Service Please complete the following: Personal details Your name: Your other names: Mr / Mrs / Miss / Ms Your partner s name: Your partner s other names: Mr / Mrs / Miss / Ms Is your partner a student? (If applicable) Yes No Access to Learning Fund (Hardship) 1
Your term-time address: Your vacation address (if different from term-time): Post Code: Tel. no: Mobile: Post Code: Tel. no: Mobile: Your Date Of Birth: Age: What is your student registration / enrolment ID? What is your e-mail address? Which campus do you study at? City / CCE Coach Lane Distance Learning London Do you have any dependent children living with you? Yes No If Yes please list below (Name, Age & DOB): Access to Learning Fund (Hardship) 2
Please select who you live with: Live alone Live with a partner Live in shared accommodation (House/Halls) How many adults do you live with? Live with parent(s) / guardian(s) Other If other please provide further details: Do you have a car? Yes No If Yes tell us why you need one (eg: to take children to school; distance from University / placement): Course details Are you: Full-time Part-time Are you: Undergraduate Postgraduate What is your programme title? Access to Learning Fund (Hardship) 3
Programme year? Foundation / 1 st / 2 nd / 3 rd / 4 th Programme Length (Years) : Is this your final year? Yes No Are you repeating any part of your course? Yes No Month course commenced: September January March Other (Please specify). Which days do you attend University for lectures/seminars/studying? Monday Tuesday Wednesday Thursday Friday Are you undertaking a placement during this academic year? Yes No If Yes please provide details: Where is/was your placement located:... From... From... From... To... To... To... Access to Learning Fund (Hardship) 4
Income & expenditure (The following details apply for the year from 1 September 2017 to 31 August 2018) Income Annual income You Your partner Total amount Other comments (Office use only) Student loan NHS Bursary NHS Bursary; non-means tested grant Assessed parental/partner contribution Parents Learning Allowance Adult Dependants Allowance NHS Dependants Allowance Childcare Grant Social Work Bursary / PGCE Training Salary Tax Credit (Working, incl Childcare element / Child / Disabled) Other benefits eg. IS,JSA, etc Child support/maintenance Child Benefit Postgraduate loan Maintenance Grant Special Support Grant Earnings (from start of your academic year) Extra money / loans from family or friends (including rent payments) Northumbria Scholarship / Bursary Assumed TOTAL Access to Learning Fund (Hardship) 5
Expenditure Annual income You Your partner Total amount Other comments (Office use only) Mortgage/rent (after housing benefit) Council tax Transport costs to University Transport costs to Placement Car tax/insurance Car loan Transport to home address (Max. 4 return journeys per year) Hire-Purchase Payments eg. sofa Credit Card Payments Life insurance Buildings Insurance Contents Insurance Childcare Other (please do not list household bills, phone bills and food) General living expenses Study related expenses TOTAL Access to Learning Fund (Hardship) 6
Bank accounts You MUST complete a separate row for each account you and / or your partner hold. Your account details Bank account type Bank account number Overdraft limit Current balance Your partner s account details (if applicable) Bank account type Bank account number Overdraft limit Current balance Your payment bank details Give the details of the bank account into which you want to receive your payments if successful. This account must be in your own name and must be open at the time of application. Please note that missing or incorrect bank details will result in your application being delayed. Sort code Account number Access to Learning Fund (Hardship) 7
Student declaration I declare that the information on this application is correct and complete to the best of my knowledge and I have read the Statement on Data Protection above. I authorise the University to make any enquiries they wish in order to verify the accuracy of the information I have supplied. I understand that any such investigation can take place at any stage, including after an award has been made, and this could involve cancelling, deferring or reducing any payments due. I will repay immediately, any overpayment of Access to Learning Fund paid to me, either because of misinformation given by myself, change of circumstances or clerical error. I will inform the University immediately if I leave my programme, or if there are any changes in my circumstances which have any significance to this application. I understand that failure to comply with these conditions may jeopardise my standing with the University and could result in disciplinary or legal proceedings. Signed:... Date: Your application may take up to six weeks to process. Access to Learning Fund (Hardship) 8