Scholarship application

First name *

Last name *

Preferred name

Date of birth *

Gender *

Male

Female

Indeterminate/Intersex/Unspecified

Are you of Aboriginal and\or Torres strait heritage? *

Yes

Are you an Australian or New Zealand citizen or a permanent resident of Australia? *

Yes

Address *

Town *

State *

Postcode

Which Shire do you live in at time of application? *

Corangamite Shire

Glenelg Shire

Moyne Shire

Southern Grampians Shire

Warrnambool City Council

Colac Otway Shire

Phone number *

Email address *

Postal address (if different from above)

Postal town *

Postal postcode

Apply for a scholarship