Arthur Edmondson Quinn Scholarship	Application Form	Deadline for submission: 26/07/2019
Arthur Edmondson Quinn Scholarship Application Academic Years 2019-2021 Applicant Section

This section of the form must be completed by the individual wishing to apply for the grant.

SECTION 1: Personal Information
Full Name (Including any middle names)
1.2 Date of Birth
1.3 Age at time of travel
1.4 Gender
☐Male ☐Female ☐ I do not wish to provide this information.
1.5 Your permanent home address
Postcode:
1.6 Your parents' home address (If different from above)
Postcode:
1.7 Contact Number
1.8 Email Address

Section 2: Your Education
2.1 Name of current education establishment
2.2 Are you currently in full time education?
☐ YES ☐ NO
2.3 What is your current stage of education?
☐ School (Applicants must be over the age of 16) ☐ College ☐ University (Undergraduate) (Applicants must be under the age of 25) ☐ University (Postgraduate) (Applicants must be under the age of 25)
2.4 What are the current subject area's you are studying? Including predicted grades/ actual grades.
2.5 What are your proposed subject areas, that you would like to focus on in the next step of your education?
2.6 What are your career aspirations?

SECTION 3: Travel Plans
3.1 Where do you wish to travel and why?
3.2 How long will your travel be for?
3.3 Please include a full breakdown of the total cost of your travel including travel costs, accommodation, food and beverage, and costs of the activities you wish to undertake whilst you are away. We also request you to attach to the application form on submission, evidence of each of the items plus an itinerary for your travel.
Approximate dates of your travel :
3.4 Approximately how much will your travel cost be in total?
3.5 How much are you applying for from the scholarship?
3.6 Passport Details (If Applicable) We will require a copy of your passport if your application is accepted.
Issue Number Expiry Date:
3.7 How will this travel benefit your educational development? (Max 700 words)

Section 4: Financial requirements (Only to be completed if you are 18 or above)
4.1 Please tick the box below which best describes your annual household income?
☐ Less than £20,000 ☐ £20,000 - £30,000 ☐ £30,000 – 40,000 ☐ £40,000 - £50,000 ☐ £50,000 or Above
4.2 Please indicate why you believe you need this grant to travel abroad?
4.3 Please provide details of any other financial support or grants, which will be used to fund this? (For example savings, parental support, scholarships etc.)

Section 5: Signed Declaration
You will need to read carefully through the below terms and conditions and sign and date this agreement to declare that you agree to meeting these terms and conditions if your application is successful. We will not process your application if it has not been signed or dated. Please print off this signed declaration and send in a signed hard copy. We will not be able to process applications unless we have received a hard copy for all the signed declarations.
I agree that any funding awarded will be used solely for the purposes set out in this application form and that Lancashire County Council can recover any monies not spent. I will consult Lancashire County Council about any changes to my travel plans. I will await agreement of any changes from the County Council before the funds are spent. I understand that if I am under the age of 18 I am required to travel with a parent, guardian or a responsible adult. I agree that I will be responsible for any overspend on the trip, and that Lancashire County Council will not be liable for any costs in excess of any funding awarded. I agree to provide Lancashire County Council with further detailed information about my travel plans; including but not limited to, copies of travel documentation receipts, plane tickets and itinerary and acknowledge that if I am successful, I will provide documentation of these. I agree to complete the evaluation form as part of the monitoring process and provide copies of receipts and invoices within three months of returning from my travel for the full value of the grant. I understand that it is [my] [my parent's/guardian's] responsibility to purchase relevant travel insurance, and provide a copy of this documentation to Lancashire County Council at least 1 month before my travel date. I understand that if I get injured or hurt whilst away on the trip I will not hold Lancashire County Council liable for any damages incurred. I understand that the travel insurance must cover at a minimum; Medical Emergencies Personal Accident Personal Liability I understand that it is [my] [my parent's/guardian's] responsibility to ensure that my travel arrangements; including but not limited to, the travel arrangements, accommodation and itinerary, are in line with safeguarding regulations and that to the best of [my knowledge] [my parental/guardian's knowledge ] believe the travel arrangements to be safe. I understand by signing this agreement I will not hold Lancashire County Council liable for any safeguarding issue during the travel. I agree that Lancashire County Council reserves the right to publicise the succession of the trip in the local media. I also understand that Lancashire County Council may wish to publicise the success of an awarded grant and by signing the declaration below, [I] [my parent/guardian] agree[s] to the publication of any success in relation to my travel arrangements. I agree that Lancashire County Council will have the right to withhold any or the entire grant and/or request all or part of the grant to be repaid if they feel that: I have not complied with all or any of the terms and conditions of the grant. The information provided by myself was inaccurate, incomplete or misleading. The use of the grant was for a purpose, which was not in keeping with the Arthur Edmondson Quinn Bequest Trust's objects. I understand that by signing this form, if the Trustees approve the application, I am agreeing to spend the funding as stated in this application form and provide the monitoring and other information as required under the terms of the Arthur Edmondson Quinn Scholarship. Declaration I certify that to the best of my knowledge the information provided in the application form is accurate and correct. By signing and submitting this form, I agree to the funding agreement detailed here. I also understand that should this application be successful, the information contained in the application form will be used to form the basis of the funding agreement. Name of applicant (Please print in block capitals): Applicant Signature: Date

Arthur Edmondson Quinn Scholarship Application Academic Year 2019-2021 Parent/Guardian Section

This section of the form must be completed by the parent/guardian of the applicant wishing to apply for the grant, if the applicant is under the age of 18.

Section 6: Financial requirements
6.2 Please tick the box below which best describes your annual household income?
☐ Less than £20,000 ☐ £20,000 - £30,000 ☐ £30,000 - £40,000 ☐ £40,000 - £50,000 ☐ £50,000 or Above
6.3 Please indicate why you believe your child needs this grant to travel abroad?
6.4 Please provide details of any other financial support or grants, which will be used to fund this? (For example savings, parental support, scholarships etc.)

Section 7: Signed Declaration
You will need to read carefully through the below terms and conditions and sign and date this agreement to declare that you agree to meeting the terms and conditions if your application is successful. We will not be able to process your application if it has not been signed or dated. Please print off this signed declaration and send in a signed hard copy. We will not be able to process applications unless we have received a hard copy of all the signed declarations.
I agree that any funding awarded will be used solely for the purposes set out in this application form and that Lancashire County Council can recover any monies not spent. I will ensure I will consult with Lancashire County Council about any changes to my child's travel plans and arrangements, and will await agreement of the change before the funds are spent I understand that my child is required to travel with a parent, guardian or a responsible adult and that the accompanying adult must make their own financial arrangements to travel I agree that I will be responsible for any overspend on the trip, and that Lancashire County Council will not be liable for any costs in excess of any funding awarded. I agree to ensure that I provide Lancashire County Council with further information about my child's travel plans and arrangements; including but not limited to copies of travel documentation receipts, plane tickets and itinerary. I acknowledge that I will provide this documentation to Lancashire County Council along with a completed evaluation form from my child within 3 months of their return. I understand that I am liable to purchase my child's travel insurance and will ensure that Lancashire County Council is provided with a copy of the documentation at least 1 month before my child's travel date commences. I understand that if they get injured or hurt whilst away on the trip I will not hold the County Council liable for any damages incurred. I understand that the travel insurance must cover at a minimum; Medical Emergencies Personal Accident Personal Liability I understand that the Arthur Edmondson Quinn Scholarship is funding only and that the scholarship cannot take responsibility for the safety of young people. I understand that this responsibility falls on myself for ensuring that my child's travel arrangements; including but not limited to, the travel arrangements, accommodation and itinerary are in line with safeguarding regulations and that I to the best of my knowledge believe the travel arrangements to be safe. I understand that by signing this agreement I will not hold Lancashire County Council liable for any safeguarding issue during the travel period. I agree that Lancashire County Council reserves the right to publicise the succession of the trip in the local media. I also understand that Lancashire County Council may wish to publicise the success of an awarded grant, and by signing this declaration, I provide my permission for this. I agree that Lancashire County Council will have the right to withhold any or the entire grant and/or request all or part of the grant to be repaid if they feel that: I have not complied with all or any of the terms and conditions of the grant. The information provided by myself was inaccurate, incomplete or misleading. The use of the grant was for a purpose, which was not in keeping with the Arthur Edmondson Quinn Scholarship objectives. I understand that by signing this form, I have agreed to undertaken all relevant searches for safeguarding purposes in respect of the trip including travel arrangements and accommodation and agree that the travel arrangements are deemed to be safe. I also provide my permission for my child's trip to be published in the local media. By signing this form, I agree to the terms and conditions set out above. Declaration I certify that to the best of my knowledge the information provided in the application form is accurate and correct. If the applicant is under the age of 18, I the parental guardian of the applicant agree to the terms set out in this agreement. By signing and submitting this form, I agree to the funding agreement detailed here. I also understand that should this application be successful, the information contained in the application form will be used to form the basis of the funding agreement. Name of Applicant: Name of applicants parent/guardian (Please print in block capitals): By signing this declaration, you are also giving Lancashire County Council permission to use your child's travel arrangements etc. for publication of the grant. Parent/Guardian Signature: Date:

Arthur Edmondson Quinn Scholarship Application Academic Year 2019-2021 Academic Tutor Section

This section of the form must be completed by your academic tutor and must include an academic reference.

SECTION 8: Reference from Academic Tutor
8.1 Name
8.2 Job Title or Role
8.2 Name of establishment
8.3 Specialist subject
8.4 Please provide us with an academic reference for the applicant (Please use additional paper if required). Please include: How long you have known the applicant. The applicant's current progress in their studies. A character reference for the applicant. In your personal opinion, do you believe that this trip will benefit the applicants educational development and if so, how?

Declaration

I certify that to the best of my knowledge the information provided in the application form is accurate and correct.

I certify that the reference I have provided is accurate and true in respect of the nature of the applicant.

Name of Applicant:

Name of tutor (Please print in block capitals):

Tutors Signature:	Date:

Checklist for applicants:

Please ensure you have completed all sections on this form and have enclosed the necessary supporting documentation - incomplete forms cannot be processed for consideration.

I have answered all of the questions on the form.

I have completed or included all the relevant signed declarations, including the applicant's declaration, the parent/guardian's declaration (if applicable) and the academic tutor's declaration.

If applicable, I have attached a copy of my valid passport, or if I currently do not have a valid passport, I agree to obtain one and send a copy of the passport before the trip commences if my application is successful.

[I] [My Parent/Guardian] have undertaken extensive searches in respect of the travel arrangements and agree that my travel arrangements are in line with safeguarding regulations.

I have attached evidence of each item on the breakdown.

I have included an itinerary for my trip.

I have included a valid bank statement (within the last 3 months) with my application.

If submitting my application electronically, I have posted a hard copy of each of the signed declarations in the post.

In addition, please make sure that:

You have kept a clear copy of the form for your own records.

If you are successful, you are required to send Lancashire County Council a copy of your travel insurance documentation at least 1 month before my travel date.

Completed application forms must be submitted to Democratic Services via the address below by the deadline date of 26/07/2019

Telephone: 01772 530818

Email: Misbah.mahmood@lancashire.gov.uk

Postal Address: Arthur Edmondson Quinn Scholarship

Lancashire County Council

Legal and Democratic Services

2nd Floor, Christ Church Precinct

County Hall

Preston

PR1 8XJ