African Palliative Care Education Social Work Scholarship - Application Form 2015

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Madeleine Cunningham
8 years ago
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1 African Palliative Care Education Social Work Scholarship - Application Form 2015 Application Form Please make sure you have fully read the application criteria and application form guidance notes below before you begin completing this form. Applicants must complete all the sections of the form: Please note that all applications must be completed in English or French and should be legible. Any incomplete or illegible application will risk not being funded. Section One: Applicants details Mr., Mrs., Ms., Dr. Name: Job Title: Years of Experience: Social Work Qualification ( Attach scanned copy of certificate, transcript or both) Previous Education in Palliative Care: Address: Section Two: Organisation details Organization Name: Address: City: Country: Telephone: Fax: Website (if applicable):

Any incomplete or illegible application will risk not being funded. Section One: Applicants details Mr., Mrs., Ms., Dr.

2 Short description of your organisation (Max 150 words) Section Three: Description of financial need (education only or education and travel) Financial Need (choose one only and include the total amount requested) Education (fees only) amount requested in US Dollars Education and travel (fees and travel) amount requested in US Dollars If your course fees are higher than the maximum amount of grant available, how will you fund the remaining costs? Section Four: Course or conference details

requested in US Dollars Education and travel (fees and travel) amount requested in US Dollars If your course fees are

3 Name and address of the organiser of the course (please submit course programme or weblink (URL) if available) Tel: Course title: Course details (please provide a short description of the course content and outline three main topics that will be covered, 150 words maximum) Outline three learning objectives: Give reasons for why you want to attend this course: How will this course benefit palliative care in your workplace? (150 words maximum)

three main topics that will be covered, 150 words maximum) Outline three learning objectives: Give reasons for

4 How will you share what you have learned with others? (150 words maximum) Why are you the right person for us to fund to do this course? (100 words maximum)

5 Section Five: Breakdown of costs Please provide a detailed breakdown of your costs in the table below, showing how you work out the total cost. Your application will not be assessed without a detailed budget. e Unit Type Cost per unit No of units Total Notes Please indicate if you have received funding from other sources and indicate how much: Source of funding: Amount in US dollars Section Six: Timetable and grant conditions Please note that grants must be claimed within 12 months of an award being made. APCA and Global Partners in Care reserves the right to withdraw funding after twelve months, therefore it is important that you keep us up to date with progress Course start date: Course end date:

e Unit Type Cost per unit No of units Total Notes Please indicate if you have received funding from other sources and indicate how much: Source of funding: Amount in US dollars

6 Section Seven: Application support/endorsement This application must be endorsed by the Chief Executive/Director of your organisation with a signature and stamp. If the applicant is the Chief Executive/Director of the organisation then it must be signed and stamped by the Chairperson of the Board of Directors. Please provide details of the person supporting the applications below. Mr., Mrs., Ms., Dr. Name : Job title/role in the organisation: address: Tel: The person supporting the application must say in no more than 100 words why it is important that we support your application: Signature: Stamp:

If the applicant is the Chief Executive/Director of the organisation then it must be signed and stamped by the Chairperson of the Board of Directors.

7 Applicant Statement Please read the following statement and enter your name at the bottom to confirm that you accept the terms and conditions of the grant. I confirm that to the best of my knowledge the details in this application form are correct. I understand that if it is not correct, appropriate action may be taken, which may lead to no further grants being awarded to my organisation and I will ensure that grant funds received will not be misused or misappropriated in any way. In the event of any changes, postponement or cancellation of the course, I will immediately inform APCA and Global Partners in Care and I understand that I may be liable to return all funds received under this grant if it is not used for the purposes for which it is given. I understand that the information provided in this application will be used by APCA and Global Partners in Care for the processing of the application, and may also be viewed by a third party (i.e. funder) if appropriate and may be used for fundraising purposes. Once the application has been submitted with all the required supporting documents, we will aim to let you know the outcome of your application within a month of receiving it. If your application for a grant is successful, then we will send an award letter, together with an acceptance form and bank details form to your organisation. The acceptance letter would need to be signed by the person who has endorsed the grant. Please note the funds will be transferred to your organisation s bank account. We cannot pay the grant until we have received the signed forms and grant letter. Please note that payments will not be made to an individual. I accept the conditions of the applications (please tick box) Signature and date: Please contact the Programme Assistant to submit your application form or if you have any questions: socialwork.scholarships@africanpalliativecare.org.

I understand that if it is not correct, appropriate action may be taken, which may lead to no further grants being awarded to my organisation and I will ensure that grant funds received will not be

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