Cell Number :â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦â¦... E-mail: ⦠.... Cell phone number: ⦠.... Application forms will be
SPORTS SCHOLARSHIP / BURSARY APPLICATION 1.
PERSONAL PARTICULARS Surname: ……………………………………………………..
Title :…………………...
Maiden Surname, (if applicable) :…………………………… First name/s: …………………………………………………… Identity Number: ………………………………………………. Marital Status: (Circle answer)
Single / Married/
Divorced/
Widowed
Nationality ……………………………………………………… Race: (Circle answer)
Black /
Coloured /
Indian /
White
Disability: YES / NO ………………………………………….. DD Date of Birth:
MM
YY
M
F
Gender:
Postal Address: ……………………………………………………………………………………. ………………………………………………………………… Postal Code: …………………… Physical Address: …………………………………………………………………………………. ………………………………………………………………….Postal Code: …………………… Home Telephone Number: [Area Code] …… [Number] ……………………………………… Cell Number :……………………………...
E-mail: ………………………………………..
Alternate contact number: ……………………… Address while Studying: ………………………………………………………………………… ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………….Postal Code: ………………….. Telephone Number while Studying: [Area Code] ……. [Number] …………………………. Are you currently employed? YES/NO……………… If YES, please elaborate…………………………………………………………………………
1
Have you ever been convicted of a criminal offence, dismissed from employment or requested to resign? YES/NO……………. If YES, please furnish full details on a separate sheet of paper.
Did you consult a vocational counselor regarding your choice of study? (Circle answer) YES/NO
Have you previously received a Public Service Bursary? YES/NO…………… If YES please indicate the year and period: ……………………………………………………………………………………………………….
Are / were you in possession of another bursary/scholarship/ financial aid? YES / NO………….. If YES, please indicate the name of the donor: ………………………………………… Obligations attached to the bursary/scholarship/ financial aid: …………………………………………………………………………………………………………… …………………………………………………………………………………………………………… …………………………………………………………………………………………………………….
Have all the obligations been fulfilled? YES /NO If NO, please elaborate. ……………………………………………………………………………………………………………… ……………………………………………………………………………………………………………… ………………………………………………………………………………………………………………
2.
QUALIFICATIONS Last School Attended: Name: ……………………………………………………………………………………………….. Town / City: …………………………………………. Highest standard passed: ………………………………
2
Particulars of Tertiary Programme: Course of Study (BSc, BCom, etc.) for which you are applying: ………………………………………………………………………………………………………... Major subjects: ……………………………………………………………………………………... Number of years you intend studying for:………………………. Name of Tertiary Institution you intend studying at: ……………………………………………………………………………… Provisional acceptance from the tertiary institution at which you intend studying attached: Received:
Not received:
(mark applicable box)
University and/or other post school training/studies Are you presently enrolled at a tertiary institution/college? YES/NO :…………………… If YES, complete the following: Name of institution/college: ……………………………………………………………………… Address of institution/college: ………………………………………………………………….. …………………………………………………………………….. …………………………………………………………………….. ……………………………………………………………………… ………………………………………………………………………. Student number at current institution: …………………………………………………………... Name of degree/diploma: ………………………………………………………………………. Current year of study: ………………………………….. Indicate the year you started studying for the current course of studies:………………… List the subjects passed thus far: ………………………………………………………………. ………………………………………………………………... ………………………………………………………………… …………………………………………………………………
3
List the subjects that still need to be completed to obtain the relevant qualification: ……………………………………………………………………………………………………… ……………………………………………………………………………………………………… ………………………………………………………………………………………………………. ………………………………………………………………………………………………………. What is the remaining duration of your current studies as prescribed by the tertiary institution? ……………………………………… Have you ever failed any year of study? YES/NO (Circle answer) Which year? …………………………………………. Have you rewritten the examination/s for the subject/s failed? If yes, please indicate the date of the examination: ……………………………………………… ……………………………………………… ___________________________________________________________________________________ 3.
INCOME AND DETAILS OF PARENT / GUARDIAN
Please indicate the annual gross income of your parent or legal guardian should you be dependent on them during the course of your intended studies (please tick the relevant option): Single parent/guardian LESS THAN R60 000 per annum Combined both spouses LESS THAN R120 000 per annum Full name of parent/legal guardian (if applicable): ……………………………………………………………………………………………………………….. . Contact details of parent/legal guardian: Tel Number:………………………………………………. Cell phone number: ……………………………………… Address of parent/legal guardian: ………………………………………………………………… ………………………………………………………………….. ………………………………………………………………….
4
YEAR
Employer of parent/legal guardian: ………………………………………………………………. ………………………………………………..
Address of employer of parent/legal guardian:
…………………………………………………. …………………………………………………. 4.
SPORT PARTICULARS /ACTIVITIES Sport/s for which applicant is applying: …………………………………………………................ School currently representing : ……………………………………………………………………….. Current Coach: …………………………………………………………………………………………. Coach’s Telephone Number :……………………. Cell Number: ………………………………….
Have you had any injuries/illness in the past 12 months? (Circle answer)
YES/NO
If yes, have you completely recovered? (Circle answer)
YES/NO
List of Achievements (complete the table below): Indicate year played. Indicate sport played. Indicate position e.g. flyhalf for rugby, Goal-shooter for netball. st Indicate level played e.g. school 1 team, KZN U19A.SA Senior. Where applicable include achievements e.g. Times for athletics, Olympic Gold.
Letter from a referee/ sport federation confirming your achievement must be attached
SPORT YEAR
5.
SPORT POSITIONP POSITION
LEVEL
LEVEL ACHIEVE
ACHIEVEMENT
REVIEW, SUSPENSION AND EXTENSION The Provincial Administration / Department reserves the right, at any time and on any terms or conditions to: a)
review the continuation of the bursary; or
b)
suspend the bursary; or
c)
having suspended the bursary, reinstate the bursary; or
5
d) 6.
extend the period of the bursary.
DECLARATION I (student’s name/s) ______________________________________________________________ declare that I have, in this application, made complete and accurate disclosure of the required information. I understand that it is my responsibility to provide this information, and that the department is entitled to rely on the information provided by me without further checking or verification. I understand that if any of the information which I have provided is inaccurate, incomplete, not up-to-date, or misleading, even if the information was given by me in good faith and without negligence, the department will be entitled to summarily cancel, reduce or revoke any financial assistance which it has provided, and/or require me to refund any such financial assistance.
7.
Signature of applicant:
Date:
Signature of Witness:
Date:
Signature of Witness:
Date:
DECLARATION BY PARENT/GUARDIAN: (WHERE STUDENT IS UNDER 21). I have checked the information provided by my son/daughter in this application for a sports scholarship / bursary from the Provincial Administration and confirm that it is accurate, complete, up-to-date and not in any way misleading. I have also read the declaration signed by my son or daughter, as set out above, and I understand the consequences that may ensue if any of the information given in this application is inaccurate, incomplete, not up-to-date or misleading. Date:
Name of Parent/Guardian:
Signature of Parent/Guardian:
Signature of Witness:
Date:
Signature of Witness:
Date:
6
Date:
KWAZULU NATAL SPORTS AND RECREATION EXTERNAL BURSARY AND SCHOLARSHIP SCHEME Purpose of the Bursary and Scholarship Scheme: Retention and development of sporting talent in the Province Recognition and further development of individuals who have contributed towards the upliftment of sport in communities. Youth empowerment through formal capacity building programmes Addressing the scarce skills in the Province Improving the diversity and employment equity workforce profile of the Province Alleviate poverty through capacity building to facilitate employment
General Application Criteria: South African citizenship Resident in KwaZulu-Natal Preference will be given to youth, women and people with disabilities Academic results must be acceptable for entry into a tertiary institution Preference will be given to orphans or applicants with parents or guardians with limited means Learners, in Grade 10 and above, involved in a priority sporting code with representation at provincial level as a minimum. Youth (age 18-35) who have achieved at provincial and national representation. Youth (age 18-35) with two years involvement in community structures and upliftment of organized sport and recreation. Reference to be obtained from the local councilor, municipal sports officers or local sport federation.
Submission of Applications: Application forms will be available from the reception desks at all offices of the Kwazulu-Natal Department of Sport and Recreation and the Departmental website at www.kzndsr.gov.za. ENQUIRIES: Mr Francis De Jager on tel: (031) 242 1785/ (031) 242 1702. Please hand-deliver your completed and signed applications to 83-93 Jan Smuts / King Cetshwayo Highway, Highway House, 2nd floor, Mayville, Durban or post it to KwaZulu-Natal Department of Sport & Recreation, Private Bag X24, Mayville, 4058. All applications must be placed in a sealed envelope and marked for the attention of Francois de Jager, External Bursary Applications.
REQUIREMENTS: Include originally certified copies of your ID document, Include original certified documents of your National Senior Certificate or your results for June 2011 An affidavit confirming your parents or guardians economic status Referee confirming sporting talent or community involvement in sport. Written confirmation from the Federation regarding level the of sporting achievement
CLOSING DATE: 28 September 2012 7
