Student details (Please print clearly)

Applicant’s first name Applicant’s middle name/s

Applicant’s last name Home street address

Suburb Postcode Postal address

Suburb Postcode Telephone Home 0 3 Mobile Email Date of Birth (dd/mm/yyyy)

Gender (Please tick) M � F �

Government School Name Are you an Australian citizen or permanent resident of Australia?

o Yes (Please continue)

o No (You are NOT eligible for funding under this program)

Championship details

Championship title Sport Location of Championship

Town State

Championship start Date (dd/mm/yyyy)

Radial distance (km’s) from applicant’s home to Championship Venue

School Sport Victoria’s

SPORTS EXCELLENCE SCHOLARSHIP FUND

THIS SCHOLARSHIP IS AVAILABLE TO VICTORIAN GOVERNMENT SCHOOL STUDENTS ONLY BEFORE YOU START PLEASE REFER TO THE TERMS AND CONDITIONS ON THE SSV WEBSITE

Please advise the applicant’s sporting potential and achievements for their school, at a regional, state or national level; and otherwise:

Please describe how the applicant will benefit from receiving a Scholarship:

Applicant has Health Care Card: Yes / No

Principal’s signature:

Principal’s name:

Principal’s contact phone number:

Please tell us what is the most important factor about the applicant that makes them deserving of a Scholarship:

Please get your school principal to prove a statement in support of the application, including information on the applicant’s financial circumstances (health care card etc.)

SSV Sports Excellence Scholarship Fund’s Terms and conditions

1. Applicants must:• be enrolled at a Victorian Government school;• have sporting potential consistent with competing at a state representative level;• be an Australian citizen or permanent resident of Australia (within the meaning of the Australian Citizenship Act

2007 (Cth)); and• have financial circumstances that would preclude them from otherwise participating at representative level.2. Please note that no extensions of the advertised due date will be given.3. Each recipient will receive an amount not more than 50% of the compulsory cost of their participation, as

outlined on the invoice provided by School Sport Victoria, to a maximum of $800.4. The balance of the invoiced cost of participation must be met by the student (and their parent/guardian) and

may be supplemented by the sale of SSV raffle tickets and additional fundraising activities.5. Recipients must use all of the money awarded from the scholarship to fund their participation as a member of

Team Vic.6. Scholarship winners are required to submit photos, videos and written content documenting their story at the

School Sport Australia Championship.

Parent/guardian endorsement

Privacy The information collected on the application form will be used by School Sport Victoria and the Department of Education and Early Childhood Development to assess your application for funding and to perform Department functions relevant to the Sports Excellence Scholarship Fund. The Department may wish to provide certain information to the media, Members of Parliament, local governments and other agencies for promotional purposes associated with the Sports Excellence Scholarship Fund. The information provided will only include the applicant’s first name, surname, age, town, school, sport, event and grant. Information collected on this form will be retained as required by the Public Records Act 1973 and other relevant Acts and regulations. The information collected is subject to consideration for release under the Freedom of Information Act 1982. If you have any further questions regarding your privacy, please contact School Sport Victoria by e-mail at school.sport.victoria@edumail.vic.gov.au or by phone at (03) 9488 9466.

Submit Your Application

Applications may be submitted by: Mail to: School Sport Victoria P.O. Box 13, Coburg, Victoria, 3058

Email to: school.sport.victoria@edumail.vic.gov.au

Fax to: (03) 9488 9499

Hand delivery to: 189 Urquhart Street, Coburg, Victoria, 3058

If you choose to use mail, email or fax, please confirm receipt of your application by phoning School Sport Victoria on (03) 9488 9466.

I have read and agree to the Terms and Conditions outlined above and certify that all information provided in the funding application is correct. My signature below signifies agreement to the conditions of this offer. Parent / Guardian’s name

Signature Date (dd/mm/yyyy)

Please submit your application including the signed Terms and Conditions to School Sport Victoria by the closing date