Dorothy Dolling Memorial Trust Fund

Application form for small grants

Name

Birthday

Day

Month

Year

Country Address

(must be outside the Metropolitan area of Adelaide)

Email

Contact Number

Details of education/training/activity

(eg name of study and where you are studying)

Referee Details

This person should be in a position to verify details of the

application, should the Trust seek further information.

Referee Name

Referee Email

Referee Phone

Witness Details

Witness Name & Address

Witness Phone

Must be a independent witness, not family

Criteria Checklist

Must be a woman or child/student seeking financial support to further their education & training. This activity to be undertaken in the year the grant is awarded.

1. I have met the core criteria:

We need evidence of education and training (A) provide a print out of your University subject enrolment or TAFE module enrolment (eg Introduction to Biology, Hairdressing 101), OR (B) a print out of your official study timetable; OR (C) provide a letter from your instructor detailing the classes you intend to undertake; OR (D) provide a document that confirms you are/have been employed as a trainee/apprentice & the study supports the work you are undertaking.

I have attached Evidence

2. I have met the location criteria:

(A) Must currently live in a country district of South Australia (outside the Metropolitan area of Adelaide), or (B) normally reside in a country district in the State of South Australia (outside the Metropolitan area of Adelaide) but are temporarily residing elsewhere for education purposes.

(Metropolitan area of Adelaide = postcodes that begin with 50** or 51**)

I have attached evidence

3. I have met the education criteria:

(A) must have completed a total of 5 years of schooling (primary or secondary) in rural, regional or remote location; OR

(B) must have completed 2 out of last 5 years of schooling (primary or secondary) in rural, regional or remote location; OR

(C) must be intending via this grant, to study from a rural, regional or remote location.

4. Have you previously been successful in obtaining a Dorothy Dolling Memorial Trust Grant?

Yes

No

Other

Do you give SACWA permission to use your name for publicity purposes

Yes

No

Do you give SACWA permission to use your photograph for publicity purposes

Yes

No

Signature of Applicant

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Date

Day