S.H.E.W. Program Application Form Sport Health Exercise & Wellbeing Section A – Applicant Details Title:MrMrsMsMiss Surname (Head Tenant) First Name (Head Tenant) Address: ACTNSWNTQLDSATASVICWA Postal Address: (if different to above) ACTNSWNTQLDSATASVICWA Email: Home Phone: Mobile Phone: Child's Full Name: Birth Date: Age: Gender: MF MF MF MF Please provide details of the activity and/or club your child will be participating in: Club Name: Club / Organisation Address: Activity e.g. footy, gymnastics: Child 1. Child 2. Child 3. Child 4. Child 5. Are you an Australian citizen or permanent resident?YesNo Do you give Pacific Link and your parent/guardian permission to contact each other about your application? YesNo Your Connection to Community Housing. Please provide the details of the person who is the main tenant in your household. Title:MrMrsMsMiss Surname (Head Tenant) First Name (Head Tenant) Home Phone: Mobile Phone: If you are unsure of these details, please contact the office on 4324 7617 or 1300 654 973 toll free for further advice. Section B – Additional Information Note: this information will help us better understand your reasons for applying for the SHEW Program Name of Applicant Are you a person: of Aboriginal or Torres Strait Islander origin? NoYes, AboriginalYes, Torres Strait Islander from a language background other than English? NoYes If "yes", please specify: with a disability? NoYes If "yes", please specify: with special conditions at home? (e.g. Caring for children or living away from home) NoYes If "yes", please specify: How did you find out about the SHEW Program? InternetPLH Tenant NewsletterOther If "Other", please specify: Section C – Applicants Statement Why do you want the SHEW Funds? How will you use it to improve your health and wellbeing? Are there any other special circumstances that you haven’t mentioned? Section D – Applicant Declaration Note: this section must be completed by the applicant or a parent or guardian if applicant is under 16 years. Full Name of Applicant Provision of Personal Information I certify that the personal information provided in this application is correct YesNo I am over the age of 16 years (if you tick ‘no’ your parent/guardian must sign this form) YesNo Provision of Personal Information to Administer and disburse the funds I give permission for Pacific Link Housing to collect use and disclose my personal information in this application form only for the purposes of assessment and administration of the SHEW Program 2012. Without this permission, it will not be possible to award the Funds. YesNo Release of details for Publicity There may be situations where your personal details cannot be released to the public. Consent to publicity and/or public release of personal details in the media is voluntary and will not affect the assessment of applications. If I am awarded the SHEW Program funds, I give permission for Pacific Link to use and release my first name (second name only with written consent) and a description of the Program along with my success story for publicity purposes. YesNo If I win the SHEW Program funds, I give permission for Pacific Link to use any photographs of me (e.g. from presentation ceremonies) for publicity purposes. YesNo Applicants who are 16 years of age or older at the time of this application, may sign this declaration. Where an applicant is under 16 years of age, this form must be signed by the applicant’s parent or guardian. Name: Address: ACTNSWNTQLDSATASVICWA Parent/Guardian’s address if DIFFERENT to applicants address: ACTNSWNTQLDSATASVICWA Contact Phone Number: Date: Sign Here > Use your computer mouse to sign in the signature box. If you are on a mobile device you can use your finger. GUIDELINES TO COMPLETING THE APPLICATION FOR Section A - Applicant details (compulsory information) In this section, fill in the full details of the applicant applying for the SHEW Funds. Full details are required as incomplete forms may not be considered any further. Date of birth – Fill in your date of birth. If you are aged under 16 years, please include the name and contact details of your parent/guardian. Australian citizen/permanent resident – You must be an Australian citizen or permanent resident to be eligible for the Pacific Link Housing SHEW Program. Section B - Additional Applicant Information (optional information) Please indicate if you: are Aboriginal and/or Torres Strait Islander are from a language background other than English have a disability You may like to tell us about any previous awards you have received. This will provide us with further background information. Section C – Applicant’s Statement (compulsory information) Completing the statement – You, the applicant, must complete the questions describing how you would benefit from receiving the SHEW. Space is provided on the application form to write your statement. Provide enough information in this section to fully answer each question. This is the information we will use to assess your application. Section D – Applicant’s Declaration (compulsory information) Provision of personal information – It is compulsory for you, the applicant, to certify that the personal information provided in the application form is correct. If this is not acknowledged, the application may not be considered any further. Provision of personal information to administer and disburse funds – It is compulsory for you, the applicant, to acknowledge that information from the application form (including personal details) will be collected, used and disclosed by Pacific Link Housing only for the purpose of assessing the application and administering funds for successful applicants. If this is not acknowledged, the application may not be considered any further. Release of details for publicity – There may be personal situations where an applicant’s details cannot be released to the public. Consent to publicity and/or public release of personal details in the media is optional and will not affect the assessment of the application. Signature – If you are 16 years old or over (at the time of the application), you must sign the declaration. If you are under 16 years (at the time of the application), your parent/guardian must sign the form.