BEAP - Bray Education Access Programme 2012-2013
APPLICATION FORM 2012
Personal Details Registration/Received by BAP Date: ______
Please ü the relevant boxes and complete fully in BLOCK CAPITALS
1. Name2. Student I.D. No.
2.a. PPSN
3. Home Address
4. Telephone/Mobile No.
5. E-mail Address
6. Age Range / Under 18 / q / 26 – 35 / q / 46 – 55 / q
18 - 25 / q / 36 – 45 / q / Over 55 / q
7. Gender / Male / q / Female / q
8. Nationality / Irish / q / Other EU Country / q
Other European (Non EU) Country / q / Outside Europe / q
9. Employment Status/ Pre-Training Status
Please select the category (ies) most relevant to your current situation or that of your family member. What was your current employment status prior to commencing further/higher education. / Live Register less than 1 year / q / Self Employed / q
Live Register more than 1 year / q / Employed: Full-time / q
Live Register more than 3 years / q / Employed: Part-time/Short-term / q
Live Register more than 5 years / q / Employed: Labour Market Scheme – CE, JI / q
Unemployed/Seasonally employed / q / Full time education (e.g. direct progression from post-primary education into third level education) / q
Unemployed but not on Live Register / q
Low Income Family Unit / q
10. Education History
Please give details of your educational history to date and indicate any qualifications you have achieved. / No formal education / q / Leaving Certificate: Standard / q
Primary education only / q / Leaving Certificate: Vocational / q
Junior/Inter/Group Cert. / q / Leaving Certificate: Applied / q
Apprenticeship / q / FETAC (ECDL, NCVA, CERT, etc.) / q
Traineeship / q / HETAC/Third Level Qualification / q
Other - Please state / q
11. Target Group
Please select one or more options / Individuals who are Unemployed (less than 1 yr) / q / Travellers / q
Individuals who are Unemployed (more than 1 yr) / q / Early School Leavers / q
Individuals who are Unemployed (more than 3 yrs) / q / Low Income Smallholders / q
Asylum Seeker / q / Family Carers / q
Disadvantaged Man / q / Homeless Person / q
Drug/Alcohol Misuser / q / Refugees / q
Lone Parents / q / Prisoners/Ex-prisoner / q
Disadvantaged Women / q / Offenders / q
Non-Irish National / q / Lesbian, Gay, Bisexual & Transgender people / q
Low Income Families / q / Older People (over 55’s) / q
People with Disabilities / q / Underemployed (seasonal worker) / q
12. Referred from
Only select one option / Publicity Campaign / q / Outreach Office / q / Outreach Visit / q
Internal Referral / q / Self-Referral / q / LESN / q
Local Community Group / q / Other LDC / q / Dept. Social Prot. / q
FÁS / q / HSE / q / VEC / q
Other State Agency / q / Other State Dept. / q / EU Programme / q
Dept. Ag. & Rural Dev. / q / Farm Organisation / q / Teagasc / q
Course Details
13.a. What is your course of study e.g. Leaving Cert., Repeat Leaving Cert., B.A. English and History, B. Sc. Science?13.b. Further Education/College Details
Please state details of the college you are attending – VEC, College of Further Education, Institute of Technology and/or University. / Name of School/College:
School/College Address:
School/ College Tel. Number:
Course Co-ordinator/Tutor:
13.c. Award upon completion of Course/Exams e.g. Cert, Dip, B.A., B.Sc. etc.
13.d. Duration of Course
/ Is this course full time/part time/modular?Full-time / q / Part-time / q / Modular / q
How long is this course of study?
1 year / q / 2 yrs / q / 3 yrs / q / 4 yrs / q
Number of hours in course per week
13.e. Current Year in Course
Please indicate if you are repeating
/ 1st / q / 2nd / q / 3rd / q / 4th / q / other(please state)
Applied / Received / YES / NO / AMOUNT
14. Are you in receipt of funding from any of the following sources?
*Indicate the month in which the first grant payment is due to be received in 2012-2013 session
Month______/ Student Universal Support Ireland (SUSI) / q / q / q / q / €
Renewal Wicklow County Council/Wicklow VEC Grant* / q / q / q / q / €
Access Grant / q / q / q / q / €
B.T.E.A. / q / q / q / q / €
Rent Allowance / N/A / N/A / q / q / €
Disability Allowance / N/A / N/A / q / q / €
Carers Allowance / N/A / N/A / q / q / €
Parental Support / N/A / N/A / q / q / €
Spouse/Partner Support / N/A / N/A / q / q / €
YES / NO
15. Are you in receipt of any bursaries, scholarships or grants other than the maintenance grant in the 2012-13 session? / q / q
AMOUNT
15.b. If you answered yes to Q. 15, please indicate the name of the bursary, scholarship or other grant / €______
Financial Details
16. Please detail what financial support is currently available to you on a weekly/ongoing basis:
Type / Weekly Amount / Monthly AMountPart time work / € / €
Family contribution / € / €
Loans / € / €
Maintenance Grant / € / €
Back to Education Allowance / € / €
Scholarships/College bursary / € / €
College Access fund / € / €
Other benefits e.g. rent allowance, children’s allowance etc. / € / €
Total AMOUNT / € / €
17. b Employment during the academic year / YES / NO
Are/Will you engaged in part-time work during 2012-13 session? / q / q
If Yes, will you work up until exams? / q / q
If Yes, will you work for some of the year? / q / q
17. c Expenditure on a weekly basis/ongoing basis:
Type / Weekly Amount / Monthly AMount
Rent/Mortgage/House contribution / € / €
Food/Groceries/Clothes / € / €
Household heating/Gas/ESB/ Oil Bills/ Telephone/Internet / € / €
Transport/Car/Petrol / € / €
Childcare/Eldercare / € / €
Other (please state) / € / €
TOTAL AMOUNT / € / €
18. Request for Funding under BEAP / YES / NO / AMOUNT
Please enter the purpose/s for which you are requesting assistance stating the amount/s in the relevant boxes
Please supply original receipts with your signature on the back of the receipt
PHOTOCOPIES WILL NOT BE ACCEPTED / School/College Fees/Admin Fees / q / q / €
School/College Lunches / q / q / €
Public Transport / q / q / €
Books/Materials / q / q / €
Computer/Laptop / q / q / €
Camera/Photography Equipment / q / q / €
Childcare/Eldercare / q / q / €
Grinds/Additional Tuition / q / q / €
College Rent / q / q / €
Other Exceptional Expenses / q / q / €
Total Amount: / €
19. Please state the years you have previously received financial support through the Bray Education Access Programme (BEAP) fund or the Bray ASSET Level Programme (Millennium Partnership Fund)?
BEAP
Please tick the relevant box/boxes: / 2002-2003 / q / 2007-2008 / q
2003-2004 / q / 2008-2009 / q
2004-2005 / q / 2009-2010 / q
2005-2006 / q / 2010-2011 / q
2006-2007 / q / 2011-2012 / q
Bray ASSET Level Programme
(Millennium Partnership Fund)
Please tick the relevant box/boxes: / Note the Millennium Partnership Fund ceased in 2010.
2002-2003 / q / 2006-2007 / q
2003-2004 / q / 2007-2008 / q
2004-2005 / q / 2008-2009 / q
2005-2006 / q / 2009-2010 / q
Additional Information – Personal STatement
This is an important part of the application and gives candidates an opportunity to explain why they are seeking this grant and to provide additional information. Please provide as much specific information as possible under the headings. Please use additional A4 sheet (not exceeding 500 words) if necessary to complete this section.
20. Please state why support for your course is required, giving an account of the blockages/barriers, if any, your experience/s (For example: financial stress in household, number of siblings in household etc.)21. Please detail any additional relevant information you wish to include in your application? (For example: why you are not in receipt of a Higher Education Grant if this is the case)
declaration
I hereby declare that the above information, in applying to the Bray Area Partnership’s Bray Education Access Programme (BEAP) Fund 2012-2013 is true and correct to the best of my knowledge. Furthermore, I give permission to allow additional information of relevance to this application to be sought from, or shared with, others as appropriate.
Signed: / Date:Print Name
PLEASE ENSURE THE CHECKLIST BELOW & COMPLETE DATA PROTECTION FORM OF CONSENT:
Have you……………… (Please Ö)§ Completed the BEAP application form in type or BlOCK CAPITALS and answered all the questions? / q
§ Attached original receipts to the value of €350.00? Please sign the back of the original receipts. / q
§ Included personal/parental proof of social welfare payment (e.g. letter from local office, photocopy of your book etc.) or proof of income (e.g. recent wage slip, P60, P21, Financial records for 2011etc.)? / q
§ Attached proof of education/college status - photocopy of 2012/2013 Student Identification Card or letter from school/college confirming college status / q
§ Attached photocopy of proof of application/approval of Maintenance Grant 2012-2013 / q
Please Return completed application form & Data Consent form with support documentation to: / BEAP 2012-2013
Bray Area Partnership
4 Prince of Wales Terrace
Quinsboro Road
Bray
Co. Wicklow
Data Protection – Form of Consent
CLIENT RECORDS
When a person receives support from Bray Area Partnership (Local Development Company – LDC), we may create an electronic record from information we record on paper forms in your name on the IRIS national database. We use this information in order to be able to provide the best type of supports for you. Services that we provide to you, including information that you give to us, is added to the record. You have the right, given by the Data Protection Act of 1988 and 2003, to submit a written request for a copy of your personal information at any time.
The information we record is used only for the following purposes:
· Processing applications.
· Compiling statistical information to help us plan and improve our services.
· Analysing information about our beneficiaries for other bodies such as, Pobal and Government Departments, and producing our own statistics for publication.
To give you an example of disclosure: Bray Area Partnership are required to collect the following details of adult beneficiaries of the Local Community Development Programme – contact details, age band, education and employment status at date of registration with the LDC for supports under the programmes as well as categorisation with the beneficiary/target groups of the programme e.g. Long Term Unemployed, Lone Parents etc. The information is provided to Pobal which provides the funding to us from the Department of Environment Community and Local Government. This information is stored on a database controlled and operated by Pobal. Pobal does not share any person identifying information with its parent Dept. or any other public agencies and bodies. Pobal is a registered data controller with the Office of the Data Protection Commissioner (4860/A).
DECLARATION
I have read and understand the above statement and consent to the use and disclosure of data and information as outlined above.
Name: ______
Date: ______
Witnessed by: ______
(LDC Employee)
/ Yes, I am happy to be contacted in the event of a future evaluation of the LCDP*/ No, I do not wish to be contacted in relation to any future evaluation of the programme
*Please tick yes if you are happy for Pobal and agents of the Dept of Environment, Community & Local Government to contact you. You may be contacted directly by Pobal or external Programme Evaluators to assess your satisfaction with the service received under the Local and Community Development Programme and its impact on you. Your details will be provided to Pobal by us if you indicate yes. By indicating yes, it means that you are willing to participate in an evaluation/short survey of the programme. Those that will be contacted will be randomly selected.
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Bray Area Partnership: BEAP 2012-2013 Application Form