Child`s emergency contact and medical information

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Child`s emergency contact and medical information
TE RŪNANGA O MOERAKI INC.
EDUCATIONAL GRANTS
Purpose:
To support whānau who whakapapa to Moeraki.in furthering their studies at a
recognised tertiary institution.
Eligibility:
These grants will provide financial assistance to tertiary students who meet
the following criteria:
1.
2.
Registered as a member of Te Rūnanga o Moeraki Inc.
Attending a tertiary institution and enrolled in a course leading to a
recognised qualification.
Complete the attached Application Form, attach the following to your application, and
Send the fully completed application form on time.
Attach to your application:
1.
2.
3.
Invoice showing the course start and finish dates and tuition fees.
A deposit slip or evidence from your bank with your printed bank account number.
A passport size photo.
Please send the application form to:
Educational Grant Application
Te Rūnanga o Moeraki
Tenby Street
Moeraki RD 2
Palmerston. 9482
Applications close:
31 March 2017
Payments will be made:
June 2017
NO LATE OR INCOMPLETE APPLICATIONS WILL BE CONSIDERED
TE RŪNANGA O MOERAKI EDUCATIONAL GRANTS 2017
Application Form
1.Personal Details
M
Date of Birth
Surname
F
Sex
First Names
2.Contact Details
Postal Address
Home Phone
Work Phone
Mobile
Email
3.Bank Account Details
Bank
Branch
Account Number
Suffix
Please provide verification of bank account details with a printed bank account number e.g. deposit slip
4. Have you applied for any educational grants through Te Rūnanga o Moeraki in the
last five years?
Yes
No
If “yes”, what year(s) and were you successful with your application?
2012 Yes/No
2013 Yes/No
2014 Yes/No
2015 Yes/No
2016 Yes/No
5. Have you received any other Rūnanga scholarships/grants towards your study for 2017?
Yes
No
If “Yes” from whom and how much was received
6. Course Details
Name of your course
Name of your institute and campus
(A) I am enrolled as Ngāi Tahu at my tertiary Institute
Yes
No
(B) I have attached an invoice showing the COURSE START and FINISH DATES and TUITION FESS
Yes
No
7.Tertiary Institute Section
This section must be completed by an authorized staff member at your tertiary institute.
I hereby certify that this student is enrolled in the course stated, at this institute
Certifiers Name
Signature
Phone Number
Certifiers Designation
Stamp
8. Ngā Tikanga
What involvement have you had with Te Rūnanga o Moeraki, Ngāi Tahu, or Māori community e.g. attending
Rūnanga hui, marae, kapa haka?
9. Are any whānau members currently involved, or been previously involved, with Te Rūnanga o Moeraki?
Yes
No
If “Yes” who is/was it and how are/were they involved:
10. Tribal Information
Are you currently registered to Te Rūnanga o Moeraki
(To receive funding you must be registered)
Yes
No
Please complete the following brief whakapapa:
The beneficiary’s (applicant’s) full name and the names of both parents should be given; thereafter it is necessary to trace
only one line of descent.
Beneficiary
(Applicant)
Mother
Maternal
Grandmother
(mother’s mother)
Father
Maternal
Grandfather
(mother’s father)
Paternal
Grandmother
(father’s mother)
Paternal
Grandfather
(father’s father)
Maternal
Grandmother’s
mother
Maternal
Grandfather’s
mother
Paternal
Grandmother’s
mother
Paternal
Grandfather’s
mother
Maternal
Grandmother’s
father
Maternal
Grandfather’s
father
Paternal
Grandmother’s
father
Paternal
Grandfather’s
father
Please list your Te Rūnanga o Moeraki Kaumatua referred to in the “Ngāi Tahu Kaumatua
1848 blue book”
11. Presentation
Please tell us in no less than 500 words why you think that you are deserving of this grant, and
what benefits your qualification may be to Te Rūnanga o Moeraki.
12. Endorsement
This must be completed by a kaumatua/kuia/taua/poua, tutor/teacher who is Māori, leader of a
Māori community group or iwi representative of a Māori authority, runanga or Trust Board, e.g.
marae, church, Māori Women’s Welfare League.
(A) I endorse the applicant’s statement regarding involvement with Te Rūnanga o Moeraki, Ngāi
Tahu or Māori community
Yes
No
(B) I further endorse this application because
Endorser’s Name
Signature
Endorser’s Designation
Date
13. Declaration





I certify that all information supplied in this application is true and correct.
I consent to this information being made available to Te Rūnanga o Moeraki for statistical purposes.
I consent to information contained in this application, including my photo, being used for Te Rūnanga
o Moeraki publications.
I give consent to Te Rūnanga o Moeraki to maintain a permanent record of my presentation on file.
I understand that this application form maybe destroyed once the application process is complete.
Applicant’s Signature
Date
14.
15.
Checklist
(a)
Application Form fully and accurately completed

(b)
Verification of bank account number attached

(b)
Invoice showing course start and finish dates and tuition fees
attached

(d)
Passport size photo attached

(e)
Details completed on Acknowledgement Receipt

Acknowledgement Receipt
APPLICANTS MUST COMPLETE THEIR DETAILS ON THE ACKNOWLEDGEMENT
RECEIPT BELOW. THIS RECEIPT WILL BE POSTED BACK TO YOU TO
ACKNOWLEDGE RECEIPT OF YOUR APPLICATION FORM.
TE RŪNANGA O MOERAKI EDUCATIONAL GRANT
APPLICATION ACKNOWLEDGEMENT RECEIPT
Name:
………………………………………………………………………
Postal Address:
………………………………………………………………………
………………………………………………………………………
………………………………………………………………………

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