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International Travel Grant APPLICATION If you are a student of the Australian National University (ANU) and you are selected to represent the University and/or Australia by a National Sporting Organisation OR Australian University Sport, in an underage or open/senior team, ANU Sport may provide you with financial assistance to help cover the associated costs of participating in this competition. Please note that international travel grants are only awarded to students who are enrolled at the ANU at the time of participating in the event for which they are applying to receive funding. 1. Personal Details Given Name: Surname: Date of Birth (dd-mm-yyyy): Gender: male or female Email: Home Telephone: Mobile Telephone: Are you of Aboriginal or Torres Strait Islander descent? 2. International Representation Sport and Discipline: Event Name: Selection Status: are selected or awaiting confirmation of selection Date of Tournament: Location: International Federation Sanctioning Event: National Sporting Organisation determining selection: Event Costs – approximate $ for total amount you are required to contribute: $ Please provide a breakdown (include as attachment) of total cost eg. travel expenses, accommodation, uniform, tournament registration, as provided to you by your sport’s NSO or International Federation. Letter confirming selection provided as an electronic attachment I will forward my letter of confirmation once selected Your letter must include the location and dates of tournament, travel dates and any specific training sessions you are required to attend for this event. Have you, or are you expecting to receive any sponsorship/grant funding from any other source for this event? If so, please provide details: International Travel Grant APPLICATION 3. Academic Details Student number: June 24, 2015 Faculty: Course: Semester 1 Status: (if competition before end Semester 2 Status (if applicable): part-time or of Sem. 1 please include results from full-time previous year, just state if 1st year student) part-time or full-time 2015 Year of Study: ie. 1st-4th year, honours, masters, phd Expected Year of Completion: Expected graduation round if in final year: Semester 1, Semester 2 Please attach a copy of your most recent transcript with this application Are you a registered with the EAFU program at the ANU? 4. Sporting Achievement Date Achieved (dd-mm-yyyy) State Level National Level Other significant sporting achievements over the past 24 months 5. Club: Club Affiliation: Which club do you currently compete for? Please note that students who do not compete for the ANU club may be eligible for the full International Travel Grant. Final grant amounts approved will be at the discretion of ANU Sport (contribution to university games teams will be taken into consideration). This does not include students for which there is no ANU club associated with their sport, or where it is not practical to compete for the ANU Club due to standard of competition or higher honours etc. Page 2 International Travel Grant APPLICATION June 24, 2015 6. Acknowledgement and Privacy Statement I acknowledge that the information provided by me (including any attachments) in this application is true and accurate. I understand the Australian National University reserves the right to amend or terminate the awarding of a representative sports funding grant should information provided in this application be false or incorrect. I also understand that the information provided by me is collected, stored and destroyed in accordance with the Australian National University’s Privacy Policy. I acknowledge and submit my application Date: CHECKLIST: Please ensure the following documents are included with your application: • Breakdown of total cost, provided by National Sporting Organisation or International Federation, including total expenses for participation in event for which you are applying to receive funding for • Confirmation of selection letter • Copy of most recent transcript All International Travel Grant queries should be directed to the Sport Development Manager, Jack Birtwhistle. Telephone: 02 6125 8383 Email: [email protected] Page 3