Freemasons Foundation Centre for Men’s Health Summer Vacation Research Scholarship 2017-18

APPLICATION FORM

This scholarship is available to students who wish to undertake a six to ten week research project over the 2017-2018 summer vacation period. The Freemasons Foundation Centre for Men's Health is offering multiple scholarships to undergraduate students at the University of Adelaide or other Universities. Preference will be given to students who will have completed at least 2 years of their degree in 2017 and consideration will be given to other students, based on circumstance, if projects are available.

University of Adelaide students are also encouraged to submit their application through the Adelaide Summer Research Scholarship 2017-18 round (refer to the University of Adelaide graduate studies website).

Projects offered are for a minimum of 6 weeks and a maximum of 10 weeks. The scholarship paymentis $200 per week (total $1200 to $2000).

Scholarship applications close Friday 29September 2017

1. Personal Details
Title: / Family Name: / Given Names:
Permanent Home Address:
State: / Post Code:
Home Phone Number:
Semester Postal Address:
State: / Post Code:
Semester Phone Number: / Mobile Number:
Email Address:
What is your date of birth? ……………./…………/……….. Gender : M F
Please supply your University Student Number: ______ N/A
Are you:An Australian citizen
An Australian Permanent Resident
Other (see below)
If you are not an Australian Citizen or permanent resident of Australia, do you have a current visa that extends beyond the end of February 2018? Yes No
2. University Study Details
Which undergraduate program of study did you undertake in 2017?(e.g. Bachelor of Arts)
Which University are youstudying at?
Which year of study are you undertaking in 2018?(e.g. Year 3, Honours)
What is your current GPA? (please note applications are not considered on GPA alone)
Have you received any other University prizes, awards or scholarships? Yes No
If yes, please provide details:……………………………………………………………
…………………………………………………………………………………………………
Have you applied for any other summer or vacation scholarships for the 2017-2018 summer break? Yes No
If yes, please provide details:……………………………………………………………
…………………………………………………………………………………………………
  • Note students who receive any other summer or vacation scholarships over the 2017-2018 summer break are not eligible to receive a Freemasons Foundation Centre for Men’s Health scholarship unless the other scholarship relates to a different research project.

Have you, or do you, intend to apply for Honours in 2018 (if applicable).
Yes Please indicate which University/Discipline/School …………………………………………………………………… No
3. Please give a brief outline of why you wish to undertake a Summer Vacation research project with the Freemasons Foundation Centre for Men’s Health
......
......
4. Supervisor/Project Details (to be completed by applicant & supervisor)
a) School coordinating your project / Freemasons Foundation Centre for Men’s Health
Administrative School – School of Medicine
b) Name(s) of academic staff member(s) with whom you will be working.(Must include at least one research member of the FFCMH)
c) Project title
Brief description of project
Name of Supervisor (please print)
Position Held
Supervisor’s(s) Signature(s)
Date
5. Declaration (to be completed by applicant)
I declare that the information I have supplied on this form is true and correct to the best of my knowledge.
I understand that if I am awarded the scholarship and the University of Adelaide at any time thereafter forms the reasonable view that my application included false or misleading information or documentation, the scholarship may be cancelled by the University of Adelaide’s Freemasons Foundation Centre for Men’s Health and any funds I have been paid must be refunded.
I authorise the Freemasons Foundation Centre for Men’s Health to obtain such additional information deemed necessary to assess my application for this scholarship.
I understand that theFreemasons Foundation Centre for Men’s Health, University of Adelaide will not disclose any information supplied on the application form or obtained for the selection process without written consent of the applicant.
I declare that I will notify the Centre office in the event that I accept another summer vacation scholarship over the 2017-2018 summer break and that by this acceptance I am no longer eligible for a Freemasons Foundation Centre for Men’s Health Summer Research Scholarship unless the other scholarship relates to a different research project.
Applicant signature: Date:
6. Recommendation (You DO NOT have to complete this section. Head of School approval will be arranged by the Freemasons Foundation Centre for Men’s Health)
Name of Applicant: ……………………………………………………………………………………………………
I hereby recommend this applicant for a Freemasons Foundation Centre for Men’s Health Summer Vacation Research Scholarship and confirm that this is a viable project for this applicant. Funding for the project is available for the period specified, and, I confirm that the allowance will be met by theFreemasons Foundation Centre for Men’s Health.
Name of Head of School or Delegate: (please print) ………..…………………………………………………………
Position Held: Head of School…………………………………………………………………………………………………………..
Signature of Head of School or Delegate: ………………………………………………… Date: ………………………
7. Payment Details (to be completed by Head of Discipline or School)
The student will commence the six week research project on ……/……/……*
Will the FFCMH fund additional weeks beyond this six week period? Yes No
If yes, how many additional weeks are to be funded? (To be funded through the Freemasons Foundation Centre for Men’s Health)
*Please note:
  • this commencement date must be within the period from November 2017 to mid January 2018 unless otherwise arranged;
  • Students are not able to undertake the project over the University Christmas/New Year closure period.

If you have any questions about your application, please contact the Freemasons Foundation Centre for Men’s Health on (08) 8313 0514 or email:

Please forward the completed application form to:

Freemasons Foundation Centre for Men’s Health,The University of Adelaide, L6 Adelaide Health & Medical Sciences Building, North Tce, Adelaide OR Gnd Floor, Freemasons Hall, 254 North Terrace, Adelaide, SA 5005

Closing date: Fri29 Sept 2017