Football SA & Variety SA Scholarship Grant Application Form
Complete the below information to apply for the scholarship grant. Please note: all applications are not guaranteed to be a recipient of the grant. Note: You can Save your application and complete at any time.
Type of Grant
Grant Applying For
*
Please Select
Pathway Scholarship
Participation Support Grants
Micro & Inclusion Grant
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Applicant Details
Applicant's Full Name:
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First Name
Last Name
Date of Birth (DD/MM/YYY)
*
Gender
*
Please Select
Female
Male
Other
Prefer not to say
Current Football Club
FFA Number
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Parent/Guardian Details
Full Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: +61 000 000 000.
Residential Postcode
*
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Is the applicant currently registered to participate in football?
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Yes
No
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Is the applicant intending to register with a football club/program if financial assistance is approved?
Yes
No
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Disability, Disadvantage or Participation Barrier
What is the primary basis of this application?
*
Please Select
Financial Hardship
Disability
Medical/health-related barrier
Social Disadvantage
Geographic/remoteness barrier
Family circumstances
Cultural/inclusion barrier
Other
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Please briefly describe the disability and how it affects participation in football. Maximum 500 characters.
*
Does the applicant receive NDIS funding?
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Yes
No
If YES to the above question, does the applicant's NDIS plan cover, or potentially cover, the item/service being requested?
Yes
No
Unsure
If YES to the above question, have you applied to use NDIS funding for this expense?
Please Select
Yes - approved
Yes - declined
Application Pending
No
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Household & Financial Circumstances
Current Housing Situation
*
Please Select
Own Home
Mortgage
Private Rental
Public/community housing
Temporary Accommodation
Staying with Family/Friends
Other
Gross Annual Household Income (before tax)
*
Please Select
Under $30,000
$30,000 - $49,999
$50,000 - $69,999
$70,000 - $89,999
$90,000 - $119,999
$120,000 +
Does the parent/guarding receive any government or carer assistance?
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Yes
No
If YES to the above question, which assistance is received? Please select all that apply.
Carer Payment
Carer Allowance
Parenting Payment
JobSeeker
Disability Support Pension
Family Tax Benefit
Housing/Rental Assistance
Other
Number of dependent children in the household.
*
Supporting evidence of household income. Examples include: Centrelink income statement, payslip or other appropriate evidence.
*
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Funding Request - What Are You Asking the Fund to Pay For?
What type of assistance are you seeking?
*
Please Select
Club registration fees
Football participation/program fees
Playing uniform/apparel
Football equipment
Disability/inclusion equipment
Disability/inclusion support service
Travel requirement for football participation
Accommodation required for football participation
Development/Program costs
Other
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What is the club?
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What are the total registration fees?
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E.g $1,000 per season
How much has already been paid?
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What amount remains outstanding?
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What amount are you requesting from the Fund?
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Please upload club invoice or registration fee schedule.
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Would the applicant be unable to register or participate without this assistance?
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Yes
No
Unsure
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What item(s) are required? Please select all that apply.
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Playing Shirt
Shorts
Socks
Goalkeeper Apparel
Boots
Other mandatory club apparel
Other
Is this item mandatory for the applicant to participate?
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Yes
No
If NO to the above question, please explain why funding is required for this item.
Total cost
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E.g $1,500
Amount Requested
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E.g $1,000
Has the item already been purchased?
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Yes
No
Please upload the quote/invoice for the item(s)
*
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What equipment is required?
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Is the equipment required specifically because of a disability or inclusion need?
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Yes
No
If YES to the above question, please briefly provide the connection.
Is equivalent equipment already available through the club, NDIS, a health provider or another program?
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Yes
No
Unsure
Total Cost
*
E.g. $1,500
Amount Requested
*
E.g. $1,000
Please upload quotation.
*
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What football event/program is the travel or accommodation for?
*
Event/Program Start Date
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-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Location of Event/Program
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Why is the travel/accommodation necessary for the applicant to participate?
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Has the travel/event already occurred? Please note, the Fund ordinarily does not provide retrospective reimbursement for costs that have already been incurred. You may continue the application if there are exceptional circumstances you would like considered.
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Yes
No
If YES to the above question, please briefly explain the exceptional circumstances.
Total travel/accommodation cost
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Amount already paid
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Outstanding Amount
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Amount Requested
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Please upload quote/booking confirmation.
*
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Is the applicant currently participating in Football?
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Yes
No
If YES to the above, without this program/service, would the applicant still be able to participate in football?
Yes
No
Unsure
How would you describe the program/service?
*
Please Select
Required for participation
Recommended for participation
Rehabilitation related
Additional development/performance support
Other
If Medical/Rehabilitation Related, has funding been sought through NDIS, Medicare, private health insurance or another health provider?
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Yes
No
If YES to the above question, what was the outcome?
Approved
Declined
Pending
Partially Funded
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Has the item, service, registration, travel, acoommodation or activity you are requesting funding for already been paid for or completed?
*
Yes
No
If YES to the above question, Has the full expense already been paid?
Yes
No
If NO to the first question on this page, What amount remains outstanding?
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Participation Barrier
Without this funding, what is most likely to happen?
*
Please Select
The applicant will be unable to register for football
The applicant will be unable to continue participating
The applicant will be unable to attend a specific football event/program
The applicant's participation will be significantly restricted due to disability/inclusion needs
The applicant can continue participating, but with financial difficulty.
The funding would provide additional development or performance opportunities
Other
In no more than 100 words, please explain how this funding will remove or reduce the barrier to participation.
*
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Other Funding
Have you requested or received financial assistance for this same expense from another source?
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Yes
No
If YES to the above question, please select the source. Please select all that apply.
Football Club
Football SA/Football Program
NDIS
Government
Centrelink-related assistance
Private Health Insurer
Charity
School
Community Organisation
Other
Amount requested from other source.
*
Amount received/approved
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Status
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Approved
Declined
Pending
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Amount Requested & Supporting Evidence
Total Cost
*
Amount Already Paid
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Amount received/expected from another funding source.
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Amount requested from the Football SA x Variety SA Football Foundation Fund
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If the full amount cannot be provided, would partial funding still remove or partially reduce the participation barrier?
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Yes
No
If YES to the above question, what is the minimum amount required?
Please upload supporting documentation.
*
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E.g club invoice, supplier quote, travel quotation, medical/support recommendation
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Final Declaration
The information provided is true and accurate.
I have disclosed other funding received or requested for this expense.
I understand that submitting an application does not guarantee funding.
I understand that additional information may be requested.
I consent to Football SA/Variety SA contactgint the nominated club or service provider to verify costs associated with this application.
I consent to the above declaration
*
Yes
No
If the child is a successful applicant of the scholarship program, do you consent to Football SA and/or Variety SA using their name for promotion?
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Yes
No
Name
*
First Name
Last Name
Signature
*
Today's Date (DD/MM/YYYY)
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