1. Applicant details
Department ID Number
(for permanent employees)
Title / First Name / Middle name / Family Name
Home address / Postcode
Work phone / Mobile phone
Email Address
Optional information
☐Please tick this box if you are an Aboriginal person or a Torres Strait Islander*.
*An Aboriginal or Torres Strait Islander is a person of Aboriginal descent or Torres Strait Islander descent who identifies as such and is accepted as such by the community in which they live.
2. Current Employment Status
Status of employment with the NSW Department of Education (Please tick one)
☐ Permanent full-time / ☐ Permanent part-time
☐ Temporary full-time / ☐ Temporary part-time
☐ Casual / ☐ Casual Employment
☐ Ongoing Employment / ☐ Temporary Employment
Are you currently on leave? / ☐ Yes, If yes, please indicate ☐ No
Type of leave: / E.g. LWOP
Period of relief (Please specify below)
From / To
3. Current position
Name of base school / School Code
School address / Post Code
Telephone:
☐ I have discussed this application with the Principal (or Director for applications from Principals)
Principal's Endorsement
Title / First Name / Family Name
Principal Comments
Signature
Date
4. Course Details
Course Name / Professional Certificate in Education (Positive Education)
Dates / Subject 1: Introduction to Positive Education
Days 1 & 2: Thursday 17 and Friday 18 August 2017
Day 3: Friday 15 September 2017
Subject 2: Building Positive Education Communities
Days 1 & 2: Thursday 2 and Friday 3 November 2017
Day 3: Friday 24 November 2017
Venue / Rydges Sydney Central, 28 Albion Street, Surry Hills NSW 2010
5. Supporting Statement
Please attach a brief (1 page) supporting statement for your application.
The statement should demonstrate the reasons for pursuing this scholarship.
The statement should be signed and dated.
Please comment in the space provided below.
SPE/DGO Name / Position / Date
SPE/DGO Signature
I certify that the information I have provided on this form is accurate and complete. In applying, I acknowledge that personal information about me may be used by the NSW Department of Education in the interests of the proper and prudent management of the School Counselling Graduate Scholarship program.
Applicant's full name (in block letters) / Applicant's signature / Date
7. Privacy Notice
The information provided by the applicant is being obtained for the purpose of the administration of the Supported Students, Successful Students Graduate Scholarship Program by the NSW Department of Education.
It will be used by the NSW Department of Education for consideration of the applicant’s admission to the Program and the applicant’s ongoing participation in the Program.
Reasons for the collection and disclosure of information are for the purposes of consideration of the applicant’s application to participate in the Program, the applicant’s participation in the Program and other purposes relevant to the proper and prudent management of the NSW Department of Education Supported Students, Successful Students Graduate Scholarship Program.
The information is provided as part of the applicant’s applying voluntarily to participate in the Scholarship Program. The information will be stored securely.
If the applicant does not provide all or any of this information then the application will not be considered by the NSW Department of Education.
Please ensure that the application form is returned via email to: .
Applicants who are successful in obtaining a fully funded scholarship by NSW Department of Education will be required to formally submit a course admission request via the University of Melbourne online application process.
For further information please contact:
Vicki Melitas,
Psychology Service Development Coordinator
Ph. 9244 5424
Email:
School Counselling Service Graduate Scholarship Program 2017