The Christopher Wise Education Scholarship Form

The Christopher Wise Education Scholarship

GENERAL INFORMATION
What is The Christopher Wise Education Scholarship?
Created in memory of Challenge Member Christopher Wise, whose enthusiasm and commitment to the pursuit of scholarly excellence was inspirational. Chris’s family are involved in the selection process and actively support this scholarship.

WHO CAN APPLY?
To apply for the Scholarship, you must be:
– A Challenge Member living with cancer or a life-threatening blood disorder
– Aged between 5 and 18 years inclusive
– Planning to commence or continue primary/secondary/tertiary education in the year you apply

Please note: You may reapply each year until 18 years of age, however applicants who have already received an award cannot reapply.

GUIDELINES FOR PRESENTATION
1. Complete ALL sections thoroughly
2. Answer ALL questions carefully

If you have any questions regarding this form, please contact the Challenge office on 03 9329 8474 or email mail@challenge.org.au

Applicants will be notified of the results of the Scholarship by mail.
Personal Information
Applicant Full Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Gender
Address*
Street Address Address Line 2 Suburb State / Province / Region ZIP / Postal Code Country
Contact Email*
Does your family primarily speak a language other than English in the home?*
Yes
No
If yes, what language does your family speak?

Medical Information
Diagnosis*

Date of Diagnosis
DD slash MM slash YYYY

Hospital*

Doctor*

Has the patient suffered a relapse?*
Yes
No

Academic History
Are you presently enrolled at school, a tertiary institution or any other academic institution?*
Yes
No
What is the name of the School/Institution?

What year level are you currently undertaking?

What course of study are/will you be undertaking (if tertiary or specialised)?

During the period of study, what, if any, additional financial support do you expect to receive? (Including any other scholarships that you have received or are applying for).

For applicants 12 and over: In 200 words or less, tell us how the Christopher Wise Education Scholarship would help you pursue your education. PATIENT RESPONSE ONLY PLEASE
For applicants under 12: What do you like most about school? What do you like to do outside of school? What do you want to be when you grow up? PATIENT RESPONSE ONLY PLEASE
Should you receive funding from the Christopher Wise Scholarship, what would the funding go towards? Please be specific.

In order to be considered for this scholarship, applicants are required to complete a Challenge Membership Form. If you have not completed a current Membership Form, please contact the Challenge office.
I, the legal guardian of the child in which this application is for, endorse and support this application and can confirm that all the information provided in this document is true and accurate at the time of signing.
Signature
Should your child receive funding from The Christopher Wise Education Scholarship, would you as a parent/guardian allow a photo and caption to be placed on the Challenge website/social media pages?
Yes
No
Other Comments

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The Christopher Wise Education Scholarship

Personal Information

Medical Information

Academic History