The Christopher Wise Education Scholarship Form

GENERAL INFORMATION
What is The Christopher Wise Education Scholarship?
This Scholarship has been created in the memory of Challenge Member Christopher Wise, whose enthusiasm and commitment to the pursuit of scholarly excellence was inspirational.

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
Full Name
First Last
Address
Street Address Address Line 2 Suburb State / Province / Region ZIP / Postal Code Country
Home Phone Number
Mobile Phone Number
Primary Contact Email
Date of Birth
Date Format: DD slash MM slash YYYY
Sex
Male
Female
Name(s) of Your Parents/Guardians:
Adult A
Adult B
Address of Your Parents/Guardians (if different from above):
Names and ages of Siblings
Diagnosis
Date of Diagnosis
Date Format: DD slash MM slash YYYY
Hospital
Doctor

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 presently in?
What course of study are/will you be undertaking (e.g. Arts, Business etc)
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).

In 200 words or less, tell us what receiving The Christopher Wise Education Scholarship would mean to you and to your education. PATIENT RESPONSE ONLY PLEASE
Should your child receive this scholarship, what will the scholarship money be used for specifically?

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
Should your application not be successful in this round of funding, would you like it to be resubmitted for the next round of funding?
Yes
No
Other Comments

Personal Information