Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
UBC Vancouver – Awards for Students with Disabilities 2014/2015
Awards for Students with Disabilities are non-repayable awards that are adjudicated on the basis of financial need and merit.
Requirements for each bursary are listed in the descriptions of each award (see award descriptions on pages 9 – 11).
Criteria





You are a student with a disability and provide supporting documentation
where indicated.
You demonstrate assessed financial need (for bursaries) by fully answering
the questions in this application.
You are a Canadian citizen or permanent resident of Canada.
You are considered a full-time student.
You meet the terms for awards eligibility set out in UBC's Regulations
Governing University Awards.
Application Checklist
 Student Application Form (pg. 2 – 7)
 Student Declaration (pg. 8)
 List of Awards (pg. 9 – 11)
 Documentation (as needed)
 Personal Statement (attach)
*Please note: Each scholarship has its own set of criteria in addition to these requirements - see the award descriptions listed on
the application
Instructions
Please read ALL the instructions before starting your application:

Submit all sections using the PDF form, print and submit by 4:00PM, October 15th, 2014.
1. Student Application Form
2. Include a brief personal statement describing your educational and career goals and summarizing your hobbies,
skills, interests, and participation in school and community affairs.
3. Student Declaration - The declaration must be completed and signed by hand. Applications without a
completed Declaration will be disqualified.


Print all parts of the application package and answer all questions carefully.
Submit supporting documentation where necessary to substantiate the nature of your disability and document exceptional
expenses by 4:00PM, October 15th, 2014.
Notify Enrolment Services in writing of any changes to the information you provide on this application.
Late, incomplete, faxed or emailed packages will not be accepted.


Timeline
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

Completed applications must be received by Enrolment Services at the above address by 4:00 PM, October 15th, 2014.
All applicants will be notified of their eligibility via email by late-November.
Recipients will have their awards/bursaries applied directly towards their tuition. Remaining funds will be available as
cheques that can be picked up from Enrolment Services. If a cheque is produced, you will be notified via email.
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Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Student Application Form
Student Information
1.
__________________________________________________
Surname
_______________________
Date of Birth (YYYY/MM/DD)
2.
__________________________________________________
Given Name
_____________
Middle Initial(s)
3.
____________________________________________________________________________________________________________
Home Phone
Cell Phone
Email
4.
____________________________________________________________________________________________________________
Address
City
Province
Postal Code
5.
Citizenship:
6.
Marital Status:  Single
______________________________
UBC Student No.
 Canadian or Permanent Resident (Landed Immigrant)
 Married/Common-Law/Same-Sex Partnership
 Separated/Divorced/Widowed
 Single Parent
General Information
7.
Degree Program
8.
Period of full-time studies:  term 1 (Sep-Dec)
Program Year
 term 2 (Jan-Apr)
 12 mths. Sep-Aug (Graduate or B.Ed. students only)
If full-time study period is Sep-Apr, please check both term 1 and term 2.
9.
Have you been out of high school for more than 48 months?
 Yes  No
10. Have you been employed in the full-time labour force for two periods of at least 12 consecutive months each?
 Yes  No
11. Is the government your legal guardian?
 Yes  No
12. Are your parents deceased and you do not have a legal guardian?
 Yes  No
13. Will you be living with your parents during the academic period starting in September?
 Yes  No
14. Will you be submitting an application for a government student loan for the 2014/2015 Winter Session?
 Yes  No
If yes, please indicate the province or territory through which you will apply:
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Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname
Given Name(s)
Middle Name
Before the Winter Session
15. How much money do you expect to earn (gross) during the summer months (May 1 to August 31)? $
16. When will/did you complete your secondary school education (high school)?
17. Secondary School Details
Month
Name of High School
Year
City
Province
18. Were you be enrolled in full-time studies during the period of May 1 to August 31
 Yes  No
(If completing high school during the months of May and June, answer ‘yes’)
19. Will you be living with your parents during the period of May 1 to August 31
 Yes  No
20. Will you be at-home caring for your child(ren) on full-time basis during the period of May 1 to August 31
 Yes  No
21. What will the total cost of your tuition and books for summer courses (not covered by student loans) be $
22. What will your childcare costs be during the period of May 1 to August 31?
$
23. What will your child support and/or alimony costs be during the period of May 1 to August 31?
$
24. What will your student loan payments be during the period of May 1 to August 31?
$
25. How much will you receive in social assistance/EI/Disability Benefits, etc. be?
$
Asset and Income Information
26. Do you own or lease a motor vehicle?  Yes  No
If yes, indicate lease or own (circle one) and give the following details:
Year
Make and Model
Purchase/Lease Date
Purchase Price
Resale Value
3|Page
Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname
Given Name(s)
Middle Name
27. The net value of the bonds, term deposits, guaranteed investment certificates, stocks and/or other investments in your name is:
$
28. The net value of RRSPs in your name is: $
29. The reported gross income from line 150 of your 2013 Income Tax Return. If you did not file a 2013 Income Tax Return, enter your
total gross income from all sources both inside and outside of Canada: $_________________________
Parental Information
If you (the student) answered “no” to all of questions 9, 10, 11, and 12 please have your parents complete this section:
30. Parent 1:
31. Parent 2:
Name
Occupation
Name
Occupation
32. Parent 1: Reported Gross Income from Line 150 of 2013 Income Tax Return:
$
33. Parent 1: Reported Net Income from Line 236 of 2013 Income Tax Return:
$
34. Parent 1: Total Income Tax from Line 435
$
35. Parent 1: Canada Pension Plan Contributions (CPP) from Line 308 and/or 310:
$
36. Parent 1: Employment Insurance (EI) from Line 312:
$
37. Parent 2: Reported Gross Income from Line 150 of 2013 Income Tax Return:
$
38. Parent 2: Reported Net Income from Line 236 of 2013 Income Tax Return:
$
39. Parent 2: Total Income Tax from Line 435:
$
40. Parent 2: Canada Pension Plan Contributions (CPP) from Line 308 and/or 310:
$
41. Parent 2: Employment Insurance (EI) from Line 312:
$
4|Page
Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname
Given Name(s)
Middle Name
42. Parental Assets: $
(do not include principle residence)
43. Voluntary Parental Contribution to the student’s post-secondary education during the period of September 1, 2014 to April 30,
2015 (includes scholarship trust funds): $
44. Number of children ages 18 and younger not attending a post-secondary institution
Ages
45. Number of children attending a post-secondary institution (including the applicant)
Ages
Dependent Information (dependents of the student)
46. Number of children ages 0-11 __________
47. Number of children aged 12-18 who are not in a post-secondary institution
48. Number of dependent children in a post-secondary institution for whom you receive the Canada Child Tax Benefit or for whom you
claim a benefit on your Income Tax Return ________________
Spousal Information
If you (the student) checked “married/common-law/same-sex partnership” in question 5, please complete this section:
49. Spouse/Common-law Partner:
Name
Occupation
50. Spouse’s Gross Income for the 4 months before classes start: $
51. Spouse’s Gross Income for the study period selected in question 8: $
52. During period selected in question 8, will spouse be at home caring for eligible dependent children on a full-time basis for the entire
study period? ……………………………………………………………………………………………………………………………………………………..  Yes  No
53. If spouse/common-law partner is a student, has he/she applied for financial assistance for this period of study? ………  Yes  No
If yes, name of educational institution _____________________________________________________________________________
5|Page
Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname
Given Name(s)
Middle Name
Student Financial Information for Study Period
Answer the following questions based on the study period you indicated for question 8.
54. What will your costs for tuition and student fees be?
$
55. What will your costs for books, instruments, and supplies be?
$
56. What will your costs for local transportation* be?
$
57. What will your costs for return transportation be (to/from Vancouver)?
$
58. What will your costs for childcare be?
$
59. What will your costs for child support/alimony be?
$
60. What will your student loan payments be?
$
61. What other expenses** do you have for the study period?
$
Please specify the types of expenses
62. How much money do you/will you have saved for this school year?
$
63. How much do you anticipate your part-time income to be for this school year?
$
64. How much will you receive in social assistance/EI/Disability Benefits, etc. be?
$
65. How much will you receive in bursaries from agencies other than UBC?
$
66. How much will you receive in scholarships (all agencies, including UBC)?
$
67. How much financial assistance will you receive from your parents?
$
68. What is your spouse’s/common-law partner’s net income?
(Including Social Assistance, EI, Disability Benefits, etc.)
$
69. How much will you receive in childcare subsidy?
$
70. How much will you receive in sponsored tuition/books?
$____________________
*Fares for all public transit are covered by the universal transit pass (U-Pass), which is automatically included in student fees. Local
transportation should include other trips, such as taxi rides.
**Exceptional expenses that are not covered under a moderate standard of living (e.g., medical expenses). These expenses require
supporting documentation to be submitted to Enrolment Services by the application deadline.
6|Page
Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname
Given Name(s)
Middle Name
71. How much sponsored funding (not including tuition/books) will you receive?
72. What other resources will you receive during the study period?
.$____________________
$
Please specify the types of resources
Voluntary Information
Information provided in this section is not mandatory, but will help in determining your eligibility:
73. If there are specific costs associated with your disability that make it necessary for you to apply for an award, explain here and list
the costs under “Other” in the budget (e.g. Purchase of equipment or special aids, payment for interpreter services, cost of
transportation, etc.). Please provide supporting documentation for additional costs.
74. Please explain the nature of your disability. If you are not registered with Access and Diversity or the Crane Library, please provide
medical documentation to substantiate your disability.
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Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Student Declaration
I have read the information on the Awards for Students with Disabilities Program that is on the Student
Financial Assistance and Awards website – www.students.ubc.ca/finance.
I hereby declare that the information on this application is, to the best of my knowledge, correct and complete. I
acknowledge that this information will be used to determine my eligibility for awards administered by UBC and
that UBC retains the right to verify information on my application. If any of the information provided in this
application should change, I understand that it is my responsibility to advise Student Financial Assistance and
Awards, in writing, of any such changes. I understand that by signing this declaration, I authorize The University
of British Columbia to: release to Selection Committee members the information provided in this application
form; release to award donors my name, contact information (mailing address, telephone number and email
address), year and program of study, and other information relevant to the requirements of the award, for the
purpose of maintaining donor relations and informing donors about the outcomes of their gifts.
Date (YYYY/MM/DD)
Signature
8|Page
Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname Given Name(s)
Middle Name
List of Awards for Students with Disabilities
All applicants must complete the following section. Using the award descriptions attached, please indicate which of the following
awards for which you qualify and wish to apply for by checking the appropriate boxes. If you do not meet the qualification criteria
for the awards/bursary, you will not be considered – please read and select carefully.
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00621
Special University Award – Jean Fulton Bursary – Bursaries totaling $5,000 are to be awarded to student(s) who
demonstrate financial need and are hard of hearing. The funds for these one-time bursaries were graciously donated to the
University of British Columbia by Mrs. Jean Fulton in memory of her son, Craig Ross Fulton. Mrs. Fulton has been hard of hearing for
the majority of her life and hopes to assist a hard of hearing student with some extra encouragement to complete their postsecondary degree.

00629
Patricia Ann MACDONALD Memorial Scholarship
A $1,050 scholarship may be awarded either in total or in part to a blind or physically disabled student. The recipient must be in a
program leading to a degree, with definite vocational goals and a high grade average. The scholarship is in memory of Patricia Ann
Palmer Macdonald, who was born in Kaslo, attended Notre Dame University, Nelson and studied privately with several members of
the UBC Music Faculty, earning three Music Conservatory degrees. She was an accomplished musician, singer, performer and a
dedicated community worker and teacher of the blind, who was blind herself at birth. She passed away in April 1982 at the age of
36. The scholarship is intended to honour a student who exhibits some of Patricia Macdonald’s qualities and talents.
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00677
Judith C. THIELE Memorial Scholarship
An $1,275 scholarship for visually or physically disabled students has been endowed by family and friends in memory of Judith C.
Thiele, B.A., B.L.S., co-founder and Reference & Collections Librarian, Crane Library and Resource Centre, UBC. Ms. Thiele was one
of the very few totally blind professional librarians in North America, an educator, academic, researcher, internationally recognized
expert on Braille transcription and special information technologies and community worker and activist on behalf of persons with
disabilities. The award is made on the nomination of the Committee on Awards for students with disabilities with preference given
to a candidate who has been active in the area of community services.

01261
Elizabeth M. CRICHTON-CARVER Memorial Scholarship
A $75 scholarship has been established by the late John A. Carver in memory of his mother, Elizabeth M. Crichton-Carver, for a
student in the Faculty of Arts. Preference is given to disabled students. Financial circumstances of the candidate may be
considered.

01438
Dennet Kuan Memorial Award
Awards totaling $1,075 have been endowed by Janet, Jennifer and Ryan Kuan in memory of Dennet Kuan (MBA, BSc) for
undergraduate or graduate students with a physical disability in any year and faculty. The award was established as a reflection of
Dennet's dedication to assisting people with a physical disability and to helping those who wish to continue their education. Dennet
was a UBC alumnus who, in 2000, set up a UBC scholarship in memory of his father, Mann Kuan. When Dennet's son was born in
1992 with complex challenges, Dennet's "we can" attitude shaped and supported Ryan in facing their world. After a successful
career in Forestry, Dennet made a career change. In his new career, he used his direct knowledge of the obstacles faced by
individuals with a physical disability to help them and their families access a variety of equipment and assistive technology needs.
Dennet passed away in 2009 at the age of 53. The award is made on the nomination of the Committee on Awards for Students with
Disabilities.
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Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname Given Name(s)
Middle Name

03512
Harriet Sarah BYRNE Scholarship
A scholarship of $575 has been endowed in memory of Harriet Sarah Byrne. The award is intended to encourage a disabled student
or a student demonstrating an interest and ability in the problems of the disabled. Preference is given to a woman undertaking
studies in the health sciences.

07595
GRADUATING Class of 1970 Bursary
A $350 bursary, endowed by the Graduating Class of 1970, is awarded to a student or students in any year and faculty. Special
consideration will be given to those with physical disabilities.

07756
Leslie Anne WHITCUTT Memorial Bursary
A $450 bursary has been endowed as a memorial to Leslie Anne Whitcutt (B.A., UBC, 1973) by her parents to provide financial
assistance for blind students who require special equipment related to their studies.

07861
Robert C. GIBSON Memorial Bursary
Bursaries totaling $750 have been endowed in memory of Robert C. Gibson. The awards are made to assist disabled students from
rural areas and preference is given to visually impaired and/or physically handicapped students.

07864
Isabel G. MCMILLAN Bursary
Bursaries totaling $625 have been endowed by Isabel G. McMillan, a member of the first graduating class at the University of British
Columbia, are offered to one or more students with sight handicaps.

07867
Douglas T. KENNY Bursary for Disabled Students
Bursaries totaling $750 are awarded to provide financial aid to disabled students. The funds have been provided by the Honourable
Thomas A. Dohm, Q.C., LL.D., and are intended especially for those physically disabled students who need wheelchairs or other
artificial aids to carry out their studies at the University.

07868
DELTA Kappa Gamma Society, Alpha Province Bursary
A $550 bursary has been endowed by the Delta Kappa Gamma Society International (Alpha Province, British Columbia), an honour
society of women educators. The award is intended to assist visually impaired students and preference is given to a student from
British Columbia.

07875
UNIVERSITY Women’s Club of Vancouver Bursary for Minimally Sighted Students
The University Women’s Club of Vancouver provides a bursary of $1,500 which may be shared if circumstances permit. In addition
to considering financial need, the academic standing of the candidate will be considered

07980
Marion COPP Bursary
A bursary of $225 has been endowed by family and friends in memory of Marion Copp who for many years resided in northern B.C.
and the Yukon. The award is made to students from rural areas and preference is given to visually impaired and/or physically
handicapped students.

08028
BURRARD Charitable Foundation Bursary for the Visually Impaired
A bursary of $850 is offered by the Burrard Charitable Foundation for a visually impaired student.
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Enrolment Services
1206-1874 East Mall
Vancouver, BC V6T 1Z1
Phone: 604-822-9836
Email: [email protected]
Name of Applicant ________________________________________________________________________________________________
Surname Given Name(s)
Middle Name

08044
PEO Sisterhood Chapter B Bursary
Bursaries totaling $1,100 have been endowed by the PEO Sisterhood Chapter B, in memory of Helen Mitchell, to assist blind
students.

08045
Steven VOLRICH Memorial Bursary
The members of the Law Class of 1984 have established a bursary of $450 in memory of their classmate, Steven Volrich. His
classmates wish to honour the courage and undaunted spirit displayed by Steven in his battle with cancer. The bursary is awarded
to a law student who requires financial assistance with preference given to a law student with a medical or physical disability.

08065
Rick HANSEN Special Needs Bursary
In recognition of Rick Hansen’s outstanding accomplishments, one or more bursaries totaling $500 are offered for students who
have special needs brought about by some physical disability. Funds for these awards were raised at the celebrity concert and
auction held at UBC in March 1987, and matched by the Alma Mater Society.

08089
Cheryl MCKAY Bursary for the Visually Impaired
Bursaries totaling $400 have been endowed through a bequest of Cheryl McKay. The awards are made to assist visually impaired
students.

08187
William Donald Mills AGNEW Memorial Bursary
Bursaries totaling $650 have been endowed through a bequest from Doris Kinloch Agnew in memory of her husband William
Donald Mills Agnew. The award is offered to students who are paraplegic or quadriplegic.

08313
Paul E. THIELE Bursary
Bursaries totaling $375 have been endowed for students with disabilities in recognition of Paul Thiele’s thirty-two years of service
to The University of British Columbia. Paul Thiele, along with his late wife Judith, was instrumental in the establishment of the
Crane Library and Resource Centre, expanding it from a collection of Braille books to an internationally recognized library and
support service for persons requiring print alternatives.

08471
Lena Adam Memorial Bursary for Students with Disabilities
Bursaries totaling $3,000 have been endowed through a bequest from Lena Adam for students who have a physical disability and
who demonstrate financial need. The award is made on the nomination of the Committee on Awards for Students with Disabilities.
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