Bursary Application Form

PLEASE NOTE THAT THE BURSARY BUDGET IS LIMITED. APPLICANTS MUST CONFIRM THAT THEY HAVE SOUGHT FUNDING FROM THEIR EMPLOYER AND BEEN UNABLE TO OBTAIN FUNDS BEFORE APPLYING FOR A BURSARY.

THE QUALITY OF YOUR APPLICATION IS VERY IMPORTANT. PLEASE GIVE CLEAR AND DETAILED ANSWERS.

ALL QUESTIONS MUST BE ANSWERED, EVEN WHERE NEGATIVE. INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.

ARE YOU USING THE LATEST VERSION OF THIS FORM? OLDER VERSIONS CANNOT BE CONSIDERED – CHECK WEBSITE BEFORE SUBMITTING

Section A: Applicant Details

Name*

Title First Surname

Address*

Street Address Address Line 2 City County / Region ZIP / Postal Code Country

Email*

Home phone*

Work phone*

Qualifications you have already obtained*

Present employer or voluntary organisation - name and address*

Employer/voluntary organisation’s website address

Your position is*

Your job title

Name of your line manager

First name Surname

Address of your line manager

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Section B: Your Past Experience

Please summarise your experience of working in the addictions field and your intended commitment to the addictions field (max. 300 words):*

Have you attended a course within the last twelve months? (If Yes, please give details and state if you received funding for this training.)*

Please give details of the most recent of any studies undertaken when in receipt of an SSA bursary:

(If none, please enter '01/01/2000' in date fields and 'N. A.' in course-related fields.)

Start date*

End date*

Course name:*

Institution providing course:*

Level of study (eg, Diploma, Certificate, Module or other):*

Please give details of the most recent of any studies undertaken, whether SSA-supported or not:

Outcome (eg, pass level/fail/unable to complete): *

_{(The outcome of any previous modules/components of this course must be provided in your application. Applications submitted without this information will be declined, so please do not submit until you have the outcome.)}

Section C: Your Intended Study

Title of the course you wish to attend*

Level of the course you wish to attend*

(eg - MSc; Foundation degree; BSc or equivalent; Diploma; Certificate in Education; Stand alone module; or Other - give details)

Course Content*

Please describe the course content and how this meets the criterion of providing 'substantial knowledge and skills in the addiction field in practice, research or policy' (max. 200 words):

Number of credits you will be studying for during the period of the bursary*

During THIS year's study activity, will you be taking:*

Name of the educational institution validating the course*

(only university-validated courses are considered):

Is it full-time or part-time?*

Is the course: Taught (face to face); Distance learning; or Blended learning?*

Number of taught hours of study per week*

Duration of study for which the bursary is requested*

(Awards are made for one study year only and must be applied for separately in subsequent years.)

Total cost of the course module(s) for the period for which the bursary is requested:*

University quote

Please attach documentation of your personal fee level in the form of a screenshot or scan of the university’s quote for this module/year of study.

Attach university quote*

Duration of study for the full qualification*

Location of the course:*

Name of course co-ordinator*

Email address of course co-ordinator*

Cost of the full qualification*

Start date for the bursary period (month & year):*

Expected finish date for the bursary period (month & year):*

IF THE COURSE extends beyond the bursary period, when did it start? (month & year):*

When do you expect it to finish? (month & year):*

How would your attendance at the course benefit your contribution to working in addictions (max. 100 words):*

How would your attendance at the course benefit your current voluntary or paid-employment provider (max. 100 words):*

Section D: Your Funding Situation

Please outline how you consider you meet the charitable aim of the bursary scheme to fund individuals experiencing difficulty in funding a course of study (max. 100 words):*

Have you applied to any other source for funding?*

Yes
No

Body or organisation applied to:*

Amount granted:*

Please state what funding is available from your employing body; For course fees:*

Please state what funding is available from your employing body for travel or other expenses:

Section E: Declaration

As part of receiving a bursary I would like to become a Student Associate of the SSA for the duration of my bursary*

[Annual fee of £25 will be paid by the SSA on behalf of bursary recipients.]

^{*Please note, submitting this application confirms applicants’ acceptance that bursaries are awarded on the basis that the recipient will complete the period of study being funded, including the formal course assessment(s), and will repay to the Society the awarded sum in full if a final assessment is not completed at the end of the period specified in the application. Students are required to submit to the Society without delay a photocopy of their completion certificate.}

Please send by post a signed letter from your Line Manager to confirm organisational support of the proposed study activity.

This is essential to the processing of the application, and to ensure bursary decisions are based on accurate, up-to-date information, must be received within 90 days of your application form. The letter of support should not be longer than one side of A4, must be on headed paper, and bear the employer/volunteer supervisor’s original signature. It must cover the following three areas:

The applicant’s ability to study at the required level, to work hard and complete the course.
The support of the employing organisation for the required time for course attendance and related studies.
A statement on any funding available, with specific amounts OR a statement if no local funding is available.

Applications cannot be considered until this letter is received.

Please send the supporting letter to:

SSA Bursary Administration, Temple Chambers, Russell Street, Keighley, BD21 2JP

Please use this box to tell us about any items that you were not able to complete using the drop-down menus:*