Telephone: 021 917 1853 Web: www.kmf.org.za Junior Scholar Programme Application Form The application and required supportive documentation should reach the Kay Mason Foundation no later than 15:00 on Friday, 31 July 2015 at the Kay Mason Foundation offices: • By hand: Office 604, Tygerberg Centre, 16 Voortrekker Road, Belville; or • Via post: PO Box 4893, Tygervalley, 7536 No email or fax applications will be accepted. Required Documents - All these documents must be attached to the Application form For Office Use No Description 1 Photocopy of Scholar’s birth certificate 2 Grade 5, Term 4 Report 3 Grade 6, Term 2 Report 4 Annual National Assessment Results Most recent results required. Your current school can provide this 5 Proof of household income: Payslip Proof of pension Proof of grant Proof of child support Proof of SASSA payments 6 3 Month’s bank statements must be provided 7 Any other supporting documents 1 1. Personal Information of Scholar Surname Name/s Name known by I.D Number Date of Birth Gender Home Language Home Address Postal code E-Mail Address Home Telephone Number Code Cellular Number School Information Current Grade Name of School Leadership Roles Current or previously held Sport Activities at school Community Involvement e.g. Reading to elderly, cleaning at aftercare Cultural Activities Special Awards/Achievements 2 2. Personal Information of Parent/Guardian: Father’s Details Surname Name/s Relationship Father Stepfather Guardian I.D Number Marital Status Married Employed Yes Employment Details Employer: Separated/ Divorced No Job Title: Never Married Pensioner Deceased Unemployed Department: Telephone Number: E-Mail Address Contact Details Home Telephone Number Cellular Number Home Address Post Code Mother’s Details Surname Name/s Relationship Mother Stepmother Guardian I.D Number Marital Status Married Employed Yes Employment Details Employer: Separated/ Divorced No Job Title: Never Married Pensioner Deceased Unemployed Department: Telephone Number E-Mail Address Contact Details Home Telephone Number Cellular Number Home Address Post Code 3 3. Financial background and family circumstances Please list ALL persons dependant on family income and living in the home. Gross monthly income includes pension, grants, child support, Sassa payments and any other support. Name and Surname Age Relationship to Scholar Type of Work Employer Name Gross Income Nett Income Total Monthly Income Please list your monthly expenses: Rent/Bond R Cell phone R Electricity & Water R Clothing R Insurance R Food R Loan/HP Agreements R Other R Entertainment R Other R Total Expenses R 4. Accommodation Information: Please tick the appropriate block House Flat Apartment Wendy House Other – Please state Room Zinc Structure Website Library 5. Where did you hear about the scholarship? At School Brochure Teacher Social Media Other – Please state 4 6. Scholar Essay. This essay must be handwritten by the scholar in his/her own words. Please write neatly. Add an extra page if more space is required. Tell us what you want KMF to know about you, your family and your home: 7. Signature By signing below, I confirm that all information provided herein is true and correct to the best of my knowledge and that any misrepresentation will result in the rejection of this application. Signature of person completing the application Date Relationship to scholar: Signature of Parent/Guardian Date 5