Charlie Bell Scholarship Application

Consent - You agree that by filling out this form you consent to us collecting the sensitive health information of your child, or another child or person for whom you are a guardian, as set out in this form.

Personal information

Applicant Name *

First Name

Last Name

What State or Territory do you live in? *

Albury Wodonga select VIC

Address 1*

Address Line 1

Address Line 2

City

State

Postcode

Date of Birth*

Are you Aboriginal or Torres Strait Islander?

Yes No

Applicant Email*

Applicant Phone*

How did you find out about the Charlie Bell Scholarship?*

Parent / Guardian Name *

First Name

Last Name

Parent / Guardian Phone *

Parent / Guardian Email *

Educational Information

Current Education Setting*

Name of School/Tertiary or Vocational Institution*

School Address*

Address Line 1

Address Line 2

City

State

Postcode

Relevant Medical History

Diagnosis*

Doctor*

Hospital where treated*

Last treatment

Selection Criteria

Outline your personal aims, achievements and personal impact, your education setting and career pursuits by completing the selection criteria below. You may choose to complete your submission in writing or via video.

Current educational setting

Personal aims

Achievements

Career pursuits and how the scholarship will help in achieving your goals

How has your illness impacted you educationally, socially and emotionally?

Video Essay

No File Chosen

File uploads may not work on some mobile devices.

Upload Video

References

Personal Written Reference*

No File Chosen

File uploads may not work on some mobile devices.

Education/ Employer Written Reference*

No File Chosen

File uploads may not work on some mobile devices.

Signature of Applicant*

[clear]

Use your mouse or finger to draw your signature above

Signature of Parent/ Guardian*

[clear]

Use your mouse or finger to draw your signature above

RMHC Australia Trust and the RMHC Chapters in Australia, (“we”, “us” or “our”) collect the personal information that has been requested from you in order to provide our service to you, accept your volunteer contribution, provide you information on the charity or process your donation and for other purposes set out in our Privacy Policy. If we do not collect the personal information that we have requested from you, we will not be able to provide our service to you, accept your volunteer contribution, receive your donation to support the much needed work of the charity or continue to inform you of the work that the charity does that directly impacts the lives of seriously ill children and their families.

Our Privacy Policy contains information about:

how we may hold, use and disclose your personal information; and
how you can access your personal information held by us and seek correction to this information.

If you have any questions about our Privacy Policy or how we treat your personal information, or if you would like a hard copy of our Privacy Policy, please contact our National Policy Officer by email privacy@rmhc.org.au or phone 1300 307 642