Redkite Dare to Dream

Redkite Dare to Dream

Redkite Dare to Dream

Scholarships are available

for 15 to 24 year olds who

have cancer or who are

cancer survivors.

You can use this form to apply for a scholarship

yourself or to nominate someone.

Applications must be received by 5pm (AEST) Friday 7 October.

A Redkite Dare to Dream Scholarship can be used:

  • To achieve education goals
    (can be at high school, at a tertiary level or work related).
  • To pursue work and career aspirations.
  • To follow a passion for a particular area of interest
    (this doesn’t have to be education or work related).

Who can apply for a scholarship?

You can apply for a Dare to Dream scholarship if you:

  • Are aged 15 to 24 (inclusive) at 30 January 2012.
  • Either have cancer or are a cancer survivor.
  • Live in Australia either temporarily or permanently.
  • Are a previous Dare to Dream Scholarship applicant or recipient provided
    you have not received the NATIONAL Redkite Dare to Dream Scholarship.
    (One National Scholarship recipient is selected each year out of all recipients.)

Who can nominate someone to receive a scholarship?

To nominate someone to receive a scholarship you will need a good

understanding of the applicant’s personal history and goals as well as

their permission to nominate them. Previous nominators have been:

• Parents • Siblings • Teachers

• Education / training professionals and advisers

• Social workers / care coordinators

• Oncologists

For more information, read frequently asked

questions at:

Nominating someone

Redkite requires nominators gain the consent of the personthey are nominating prior to submitting the scholarshipnomination form. The person they are nominating must havesigned the consent section at the back of this form.

Consent

Redkite respects your decisions however, for those agedunder 18, a parent or guardian must co-sign the declaration atthe end of this form.

Media consent

All Redkite Scholarship recipients are invited to representRedkite as ambassadors and participate in media activityto promote Redkite. Recipients are under NO obligation toparticipate in promoting Redkite and applicants will not beaffected in anyway should they choose not to take part in anymedia activity. Please complete the media consent form on page eight of theapplication to declare your/the applicant’s level of media consent.

Completing the form

For further information or if you need assistancecompleting the form, contact a member ofRedkite’s Community-based Support team:

Phone: 1300 722 644

Fax: 02 9219 4099

Email:

Web:

Please forward your completed applicationform via post, fax or email by Friday 7October 2011 to:

Emilia Armytage

Manager Financial and Material Support

Post: Redkite

PO Box 3220

Redfern NSW 2016

Email:

Fax: 02 9219 4099

Young person’s details

Title: Name: Date of birth: //

Age on 30 January 2012: Address:

Suburb/Town: Postcode: State/Territory:

Home phone: Mobile: Email:

Diagnosis: Diagnosis Date: //

Nominator details

Tick here if you are nominating yourself

(You do not need to complete this section if you are nominating yourself.)

Title: Name:

Organisation: Position:

Address:

Suburb/Town: Postcode: State/Territory:

Home phone: Mobile: Email:

Referee details

Title: Name:

Organisation: Position:

Address:

Suburb/Town: Postcode: State/Territory:

Home phone: Mobile: Email:

1. What does it mean to you? (400 words or less)

The Redkite Scholarship Program aims to support young

people whose education/studies/employment or special

interests may have been impacted by a cancer diagnosis.

What are your dreams/goals/aspirations/special interests?

How has your cancer diagnosis affected these?

Note: This question needs to be answered by the applicant, even if

being nominated. The answer can be scribed by someone else but must

be in the applicant’s own words.

Your response goes here

2. Your strengths and abilities. (300 words or less)

Please describe what you consider to be your/the young person’s

strengths, skills and abilities and how these would support you/them in

the pursuit of your/their goals, as described in the previous question.

Your response goes here

3. Your personal background. (300 words or less)

Please provide a brief personal background of yourself/the young person

(eg family, study, employment, interests, and challenges)

Your response goes here
4. How can Redkite help? (200 words or less)

How will a Redkite Scholarship help you/the young person progress

with your/their future goals and aspirations? Please include a proposed cost.

Your response goes here

5. Your commitment. (200 words or less)

Describe how you/the young person demonstrates a commitment to your/their area of study orspecial interest? (This may include work experience, courses undertaken, prizes won, certificates,public speaking, practical experience etc.) Please attach copies of supporting material (no more than5 documents) if applicable.

Your response goes here
Media Consent Form

All Redkite Scholarship recipients are invited to represent Redkite as ambassadors

and participate in media activity to promote Redkite and their services.

This opportunity generally involves the distribution of media releases to the media (print,

radio and TV) in the recipient’s state which includes their name, age, town of residence, the
nature or area ofpursuit, and information on why he/she was selected for the scholarship.
Contact details are not disclosed. Wealso like to feature scholarship announcements on Redkite-related media, which includes our newsletter, socialmedia and website.

Recipients are under no obligation to participate in promoting Redkite and we respect their right not to share

this information with the media. Applicants will not be affected in anyway should they choose not to take part in

any media activity. If the media would like to contact a recipient for an interview or photograph, a member of the

Redkite team will always contact them first to ensure they are happy to be contacted and to arrange a suitable time.

I give permission for Redkite to use my story to promote Redkite and their services:

(Please tick the appropriate boxes)

Use my name, state and suburb of residence in scholarship announcements including media releases; and toprovide a quote

Use my name and/or quote and/or photo for Redkite communications such as Redkite newsletters, the Redkitewebsite, social media and email updates

Agree to be interviewed by journalists and photographed for use in the media (for print, radio or television) and/orprovide a photograph of myself for use in the media and/or Redkite publications

I DO NOT give permission for Redkite to write a press release or use my photo or story to promote Redkite and/orDare to Dream Scholarships.

Name:

Signed: Date: //

Parent/Guardian consent (if young person is under 18 a parent must sign):

Name:

Signed: Date: //

Media consent is valid for two years. If the material is used for fundraising purposes, I realise that monies go to

Redkite, not specifically to my family.

How did you hear about the Redkite Scholarship?

Redkite websiteSocial worker/Care Co-ordinator

Other health professionalMailoutEmail promotion

Newspaper/radio/magazineTAFE/UniversityPoster

Facebook/Twitter/social mediaSchool counsellor Other

Declaration of applicant

I (name)

have completed this application myself and by signing below
hereby make thisapplication for a Redkite Dare to Dream Scholarship.

Signed: ______Date: //

Parent/Guardian consent (if young person is under 18 a parent must sign):

I/we (name/s)

being the parent/s / guardian/s of the applicant hereby endorse and support this application

Signed: ______Date: //

Declaration of nominated person

I (name)

have read this application, agree to the nomination and by signing below hereby

make this application for a Redkite Dare to Dream Scholarship.

Signed: ______Date: //

Parent/Guardian consent (if young person is under 18 a parent must sign):

I/we (name/s)

being the parent/s / guardian/s of the applicant hereby endorse and support this application

Signed: ______Date: //

Nominator declaration

I (name)

have discussed this application with the applicant and by signing below hereby make this

nomination for a Redkite Dare to Dream Scholarship.

Signed: ______Date: //

• By signing this form you agree to have your details recorded by Redkite in order to

assist us with the assessment of this application.

Medical Referee form

Redkite has been supporting young people diagnosed with cancer

for over 26 years. Getting through cancer can be tough and interrupt

study, work and other areas of personal interest in a young person’s life.
We wantto support young people diagnosed with cancer to get them
where they want to go!

The Redkite National Dare to Dream Scholarship Program is specifically for young people

who have, or who have previously had cancer.

To be eligible for consideration for a Redkite Scholarship, Redkite requires confirmation of

the young person’s cancer diagnosis.

Please ask your GP, Oncologist, Care Co-ordinator or Social Worker to complete this form.

Name of young person:

Type of cancer diagnosed:

Date of diagnosis:

Type of treatment:

Duration of treatment:

Hospital:

Treating Oncologist:

Medical Referee signature:

Please attach this medical referee form to your nomination form when returning

to Redkite. The Redkite Scholarship Program applications close on:

Friday 7 October 2011.

For further information please contact a member of the

Redkite Community Based Support Team:

Phone: 1300 722 644

Email:

Post: PO Box 3220

Redfern NSW 2016

Website:

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