/ Caboolture Campus Student Assistance Scheme
Application Form

INFORMATION FOR APPLICANTS ABOUT THE CABOOLTURE CAMPUS STUDENT ASSISTANCE SCHEME (CCSAS)

The Caboolture Campus Student Assistance Scheme targets students from low-income backgrounds or students who face significant financial barriers to studying at university. Assistance is available to students able to demonstrate financial difficulties for the purposes listed below. Assistance provided will be dependent on available funding.

WHO IS ELIGIBLE?

All students experiencing financial difficulty who are enrolled in courses at the Caboolture Campus are eligible to apply.

DUE DATES

Applications close end of week 1 of each semester

Graduation bursary closes end of week 12 of semester

FURTHER INFORMATION

For further information please contact the Student Engagement Officer Ph: 5316 7461 or

IMPORTANT NOTE:

All information and documentation supplied by you will be treated confidentially and in accordance with QUT's Privacy Policy. It will only be disclosed to QUT staff involved in the selection process. For more information on privacy at QUT, including QUT's privacy plan go to www.governance.qut.edu.au/compliance/privacy/obligations.jsp

PERSONAL DETAILS
Name / Click here to enter text.
Student No / Click here to enter text.
Mobile / Click here to enter text.
QUT Email / Click here to enter text.
Course Code / Choose an item. / Year Level
(e.g. 1st or 2nd year student) / Choose an item.
Do you identify as an Aboriginal and/or Torres Strait Islander Person
(Yes / No) / Choose an item.
INDIVIDUAL & FAMILY FINANCIAL SITUATION
Your Situation
Which one of the following describes your current situation? / Single - living at home and supported financially by family / ☐ / Complete Section 1 & 2
Single - living at home with parent/guardian and financially independent (i.e. share all expenses) / ☐ / Complete Section 1 & 2
Single - living away from home and supported financially by family / ☐ / Complete Section 1 & 2
Single - financially independent / ☐ / Complete Section 1 only
Sole parent/Carer / ☐ / Complete Section 1 only
Partnered, no dependants / ☐ / Complete Section 1 & 2
Partnered, with dependants / ☐ / Complete Section 1 & 2
Other (please specify) / Click here to enter text.
Number of dependants (under 18) that you support / Click here to enter text.
If you are supported by your parents(s)/caregiver(s) or partner, number of dependants that they support / Click here to enter text.
SECTION 1: Your Individual Financial Situation
Which of the following Centrelink benefits (full or partial payment) do you personally receive? / Abstudy / ☐
Aged Pension / ☐
Austudy / ☐
Carer’s Payment / ☐
Disability Support Pension / ☐
Family Tax Benefit A and/or Family Tax Benefit B / ☐
Newstart / ☐
Parenting Payment (single or partnered) / ☐
Youth Allowance / ☐
None / ☐
Other (please specify) Click here to enter text.
Your annual gross Centrelink benefits
If you receive income from Centrelink you must supply a Centrelink Income Statement. / Click here to enter text.
Your annual gross (i.e. before tax) income
Please provide documentation showing all income sources for the past 12 months e.g. Tax Assessment Notice for the last financial year, most recent pay slips. / Click here to enter text.
If your income is expected to change in the next financial year please give an explanation and an estimate of your future income. / Click here to enter text.
SECTION 2: Your Family’s Financial Situation
For all students financially dependent on their family or partner we need to know the nature of your family's financial situation in order to assist us in determining your level of financial need
Which of the following Centrelink benefits (full or partial payment) do your parents/caregivers or partner receive?
NOTE TO PARENTS/CAREGIVERS: Information requested on this form will be treated confidentially and sensitively. If you do not wish to disclose your financial information to your dependant, you may submit this documentation in a sealed envelope with this form. If you have any concerns, or questions, please telephone the Student Engagement Officer on 5316 7461. / Abstudy / ☐
Aged Pension / ☐
Austudy / ☐
Carer’s Payment / ☐
Disability Support Pension / ☐
Family Tax Benefit A and/or Family Tax Benefit B / ☐
Newstart / ☐
Parenting Payment (single or partnered) / ☐
Youth Allowance / ☐
None / ☐
Other (please specify) Click here to enter text.
Your family's/partner’s annual gross Centrelink benefits
Please provide parents/ caregivers or partner’s Centrelink Income statement / Click here to enter text.
Your family's/partner’s annual gross (i.e. before tax) income
Please supply documentation showing parents/ caregivers or partner’s income sources for the past 12 months e.g. Tax Assessment Notice for the last financial year, most recent pay slips. / Click here to enter text.
Financial Hardship
Tell us about the impact of your financial situation (and your family's financial situation if you are supported by them), on your life and studies.
Some examples:
·  missing out on basic needs
·  ability to pay bills
·  missing out on leisure or hobby activities
·  significant expenses outside norm such as medical expenses
·  high transport costs
·  childcare expenses
·  other hardship and deprivation
This section must be completed to assist your application.
You can provide information on the space below, however if you wish to provide further information please attach information on a separate page.
Click here to enter text.
AVAILABLE ASSISTANCE
All Students
Textbook Loan / ☐ / You must complete prescribed textbook details below
Photocopy/Printing Credit / ☐ / $25
Nursing Students
Uniform for Placement / ☐ / Students can only receive one free uniform per year
LSB182 Lab Coats / ☐ / Only if enrolled in LSB182
Hepatitis B Vaccination / ☐ / Vaccinations through United Medical Centre
TEXTBOOKS
The Textbook Loan Scheme is for PRESCRIBED textbooks only
Unit Code / Unit Name / PRESCRIBED TEXTBOOK/S
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text.
Declaration
I declare that, to the best of my knowledge and belief, all the information I have provided is true and correct.
Signature: Click here to enter text. / Date: Click here to enter text.

Please submit your application to:

Student Engagement Officer

Careers, Counselling & Welfare Reception

QUT Caboolture Campus