Hector Naidoo and Associates Future Leaders Bursary BURSARY APPLICATION FORM

Hector Naidoo and Associates Future Leaders Bursary BURSARY APPLICATION FORM

SECTION 1 Dear applicant, We have pleasure enclosing an application form. When completing the form, please take note of the following: Read the instructions carefully. Return the application form to our head office before 10 February. Completed application forms must be submitted via to email address: marc@hnaphysiotherapy.co.za. Applications that are not 100% complete will not be considered. Please ensure that all the requested documents are attached. 1. Selection criteria 1.1 Only applications from South African citizens will be considered. 1.2 The main criteria for the selection of applications are based on financial need, academic potential and for previously disadvantage students classified as Black African, Coloured, or Asian. 1.3 Bursary applications are invited from students who are studying full time towards an undergraduate university (academic) degree in B.Sc. Physiotherapy: 1.3.1 Applicants who are entering their 4 th (final) year of study towards their B.Sc. Physiotherapy. 1.3.2 Applicants who obtained a minimum average of 60% for subjects in their 2 nd or 3 rd year of study towards their B.Sc. Physiotherapy. 2. Instructions for submission of application forms 2.1 Applications will only be considered if completed in full and signed by the applicant and if all the supporting documents have been included. 2.2 Documents that accompany the application form must be certified (see checklist below). Please tick the appropriate box if you have included a certified copy of the specific document. (Your application will not be considered without the relevant documentary proof, as applicable). 1 Certified copy of your I.D. 2 Official Matric/grade 12 results 3 2 nd and/or 3rd year tertiary (B.Sc. Physiotherapy) results 4 Proof of your residential address or affidavit confirming your residence. 5 Proof of your banking details. 3. Bursary amounts For the 2018 Academic year successful applicants received funding assistance for their registration fee to the value of R5000. Terms and conditions apply. 2

4. Terms and conditions 4.1. The financial aid given is for your Registration Fee Only. 4.2. The applicant agrees to participate in four health promotion talks for the year, during their vacaction periods, to be identified by the partners of Hector Naidoo and Associates. 5. Completed application forms: acknowledgement of receipt Applicants will be notified via email when their application form has been received. Only completed applications will be considered and selection will take place from 11 February 2018. All applicants will be notified of the shortlisting outcome via email no later than 20 February 2018. Please contact Samantha Fortuin only if you have not had a response by 20 February 2018 on 021 828 2484. Please note that only selected candidates will be shortlisted for this prestigious financial aid. Meeting the minimum selection criteria does not imply that an application will automatically be successful. Successful shortlisted applicants will be required to come for a panel interview after which the final selection will take place. 3

SECTION 2 Important: Not all who apply are interviewed. Please complete this form as thoroughly as possible as this is our only indication of your potential at this stage. Closing date strictly: 10 February 2018 2.1 Personal details 1. Surname 2. First names 3. Date of birth (dd/mm/yyyy) 4. Place of birth 5. Identity Number 6. SA Citizenship Yes No 7. Gender Male Female 8. Population group Black Coloured Indian White Asian 9. Do have a disability? African Yes No If yes, please specify the nature of your disability below: *Gender, population group and disability information required for statistical purposes 2.2 Contact Details Cell number: Alternative cell number: Email Address: Postal Address: Whose number is this? Alternative email: Postal Code: Physical Address: Is your home in a rural or urban area? Rural Urban Is the dwelling in which you live of a formal or informal structure? Rural Formal Urban Informal 4

SECTION 3 3.1 Applicant s study details Name the university you are currently registered at for your tertiary studies. Name the degree you are currently registered for. What year of study are you going into this year? What is your student number? Which career do you intend following on completion of your studies? Mention any other bursaries you have applied for as well as any bursaries that have been granted to you. School results: In the columns below please provide your school results, as applicable. Fill in the names of your other subjects in the blank spaces. Subjects 1. Mathematics 2. English [HL] [FAL] 3. Physical Science (if applicable) 4. Life Orientation 5. Other Language [HL] [FAL] 6. Mathematics Paper 3 (if applicable) 7. 8. 9. 10. 11. 12. Final Grade 12 results 5

University results: In the columns below please provide university results, as applicable. Fill in the names of your subjects in the blank spaces. Subjects 2 nd or 3 rd year B.Sc. Physiotherapy results. Please specify: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. SECTION 4 4.1 Details of parents/legal guardian and family (living in one home) The aim for this section is to establish financial need. It is therefore essential that you provide the correct income information and the required supporting documentation. Applications without precise and reliable information will be regarded as incomplete and will not be considered. Father/ Stepfather First names: Surname Marital status Married Divorced/seperated Never married Deceased Widowed Employed Yes No Pensioner Yes No Total income R (salary,wages, pension) per month Please provide proof of income or lack thereof by attaching relevant documentation Mother/Stepmother First names: Surname Marital status Married Divorced/seperated Never married Deceased Widowed Employed Yes No Pensioner Yes No Total income R Please provide proof of income or (salary,wages, pension) per month lack thereof by attaching relevant documentation 6

Legal guardian First names: (not mentioned above) Surname Marital status Married Divorced/seperated Never married Deceased Widowed Employed Yes No Pensioner Yes No Total income R Please provide proof of income or (salary,wages, pension) per lack thereof by attaching relevant documentation month Other member of your family who are living at your home and not mentioned above Name Relationship (eg brother, grandparent) Category (child, student, adult) Income month) (R/per Type of income (wages, grant, pension) 7

Section 5: Testimonial by education official I, the undersigned, testify as follows concerning the bursary applicant: Academic potential of applicant Personality and leadership qualities I recommend this applicant for a bursary because This testimonial was given by me, the undersigned, in my capacity as: of the school/ college/ university (name): 8

I can be contacted at the following telephone/ cell number Surname and initials in block letters Signature: Date: Official Stamp 9

Section 6: Testimonial by a community leader I, the undersigned, testify as follows concerning the bursary applicant whom I have known for (number) of year(s). Describe the applicant s home circumstances Describe in detail the applicant s involvement and participation in the activities of your organization/community I recommend this applicant for funding because This testimonial was given by me, the undersigned, in my capacity as: 10

Of the organization/ community (name) I can be contacted at the following telephone/ cell number Surname and initials in block letters Signature : Date: Official Stamp Community leader is anyone who holds a significant position in the community, example head of local council, NGO head, head of local police forum, religious leader, traditional leader or political leader. 11

Section 7: Essay on your life Write this essay in your own hand and: 1. Tell us about your family, including your parents current circumstances. 2. Tell us about yourself: 2.1 Describe yourself in three words. 2.2 What are your major strengths? 2.3 What are your major weaknesses? 3. What leadership position(s) have you served in and what impact has that had? 4. Mention the committees/ organizations you belong(ed) to and any community service projects you have been involved with. 5. Briefly tell us why you have chosen your field of study. 6. Tell us what defines a great leader. 7. Describe the South Africa you want to see in the next 10 years. 12

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(Use additional pages if necessary) I hereby declare that all the information given in this form and the included documents are true and accurate. Applicant s signature: Date: 15