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Transcript of education.qld.gov.aueducation.qld.gov.au/.../docs/studitalia-ap… · Web view · 2017-02-24be a...
STUDENT APPLICATION FORM [Part A]The StuditaliA Prize (StuditaliA) for Year 12 students of Italian
19 November to 21 December 2017
ELIGIBILITYTo be eligible to apply for StuditaliA, the applicant must:
be a full-time student in a Queensland high school (or college or academy), studying the Italian language and in Year 12
be an Australian citizen, permanent resident of Australia or a New Zealand citizen residing in Australia not have spent more than four months in Italy (visiting or living) nor attended an Italian educational
institution for more than a term within the last five years not speak Italian (or related dialects) as a first language or be the primary language at home have long term goals involving the study/use of the Italian language wish to improve his/her knowledge of the Italian language and culture in other countries be available to travel from 19 November to 21 December 2017 (dates to be confirmed) possess the emotional ability and resilience to be immersed in a foreign culture and language while in
homestay, at school and on tour be in good health and fit for international travel, in accordance with the terms of cover under the Group
Medical Conditions (group policies) listed by GoSafe Travel Insurance disclose personal information where required for travel and health insurance purposes to ensure that
adequate cover is purchased have (or be willing to obtain) a current and valid passport with at least six months’ validity from 21
December 2017 be willing to participate in all activities arranged by the organisers be willing to abide by the Queensland Code of School Behaviour be willing to abide by the laws of the country they visit be willing to abide by the rules and conditions of the tour including those of any host family and host
school be willing to represent Queensland appropriately as a student ambassador accept the conditions outlined in the privacy statement of this Student Application Form [Part A] and the
Project Consent Form [Part B] meet all the requirements of the Conditions of Entry and Tour Rules [Part D] of the program to be eligible
to apply.
Student name: School name: State Catholic Independent Other
Privacy Statement: The personal information provided will be used for planning and organising The StuditaliA Prize 2017, obtaining travel insurance, making arrangements to cater for special requirements (where possible) and for the purpose of assisting the Department and chaperones to fulfil their duty of care. This information will be given to supervising staff and chaperones accompanying the overseas tour. Some of the information provided will be disclosed to insurance organisations, tour operators, airlines, travel companies, accommodation providers and other external parties involved in providing services to the group as part of the tour. Relevant information will be given to medical professionals in the event the student requires medical attention on the tour or while in the care of the Department. The personal information and copyright material will also be dealt with in accordance with the Project Consent Form (Part B). The information will not be used or disclosed for any other purpose without your consent unless the use or disclosure is required or authorised by law. If you have any questions or concerns about the collection, storage, use or disclosure of the information, please contact the Project Officer on 3513 5710.
APPLICANT DETAILS
NameSurname
Given Name/s
Date of Birth DD/MM/YYYY
Citizenship Australian Citizen Australian Permanent Resident New Zealand Citizen residing in Australia
AddressStreet
Town/Suburb/City Post Code
Phone number Home: Mobile:
Email AddressSchool
Private
Parents/Guardians
Full Name
1 2Phone
First language
PASSPORT DETAILS (attach scanned copy of passport photo page)
Name as appears on Passport
Passport Details Number Expiry Date
Country of Issue Nationality
I am in the process of applying for my passport (attach scanned copy of birth certificate)NB: Successful applicants will require a passport no later than one month after advice of acceptance
into the program
SPECIAL REQUIREMENTSPlease consider the information you have provided and all information about StuditaliA and provide details of any special requirements you may have for StuditaliA if your application is successful. For example: adjustments for impairment; mobility aides or assistance; religious requirements; medical conditions; dietary requirements (such as allergies, halal, vegetarian, gluten free); any special requirements for air travel or accommodation. If you do not have any special requirements, please indicate N/A below. Further information may be requested to assess if and/or how your special requirements can be accommodated on the tour.
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SECTION ONE
Student name: School name: State Catholic Independent Other
SCHOOL DETAILSSchool Name
AddressStreet
Town / Suburb / City Post Code
Principal Phone
Email address
Italian teacher^ Phone
Email address
^ If student is successful with application, you will be included in all email correspondence during preparation of the tour.
MOST RECENT ITALIAN GRADES/RESULTS*(Please outline below)
*Please attach a copy of your most recent report card for all subjects.
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Student name: School name: State Catholic Independent Other
MOTIVATION FOR APPLYINGPART A – COMPLETE IN ENGLISH ELECTRONICALLY
Outline your commitment, now and in the future, to the study of the Italian language and culture. (Response 50 words minimum – 300 word maximum)
How will you work towards adapting and adjusting to living in a different culture? (Response 50 words minimum – 300 word maximum)
Foreign school (boarding school) Meeting new people Integrating into the community
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SECTION TWO
Student name: School name: State Catholic Independent Other
Why do you feel you are well suited to represent Queensland as a ‘young ambassador’? (Response 50 words minimum – 300 word maximum)
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Student name: School name: State Catholic Independent Other
PART B – COMPLETE IN ITALIAN IN YOUR HANDWRITING
In Italian, briefly introduce yourself and outline your reasons for wanting to participate in the program (response between 250-300 words).
This response is to be completed in the applicant’s own handwriting in Italian, be their own work and not be reviewed by anyone.
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Student name: School name: State Catholic Independent Other
What are your interests and hobbies? (Response 50 words minimum – 300 word maximum)
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Student name: School name: State Catholic Independent Other
SECTION THREE
ENDORSEMENT BY ITALIAN LANGUAGE TEACHERStatement of support for student’s application. Please reference student’s suitability, class participation, behaviour and language level (Response 50 words minimum – 300 word maximum)
Language Teacher Signature Date
Language Teacher Name (please print)
Contact DetailsPhone
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Student name: School name: State Catholic Independent Other
SECTION FOUR
ENDORSEMENT BY PRINCIPALStatement of support for student’s application (Response 50 words minimum – 300 word maximum)Include your knowledge of the student’s ability to possess:
significant leadership qualities the openness and confidence to explore new ideas and experiences self-discipline and resilience humility and ambassadorship behaviour commensurate with representing their school overseas a desire to continue the study of the Italian language for future career opportunities.
If you are aware of any issues that may prevent this student from successfully participating in this program please provide information below or email [email protected]
Principal Signature DatePrincipal Name (please print)
Contact DetailsPhone
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Student name: School name: State Catholic Independent Other
SECTION FIVE
DECLARATION OF APPLICANT
By signing below, the applicant declares:
I have read and understood the Privacy Statement in this Student Application Form [Part A] I have read, understood and signed the Project Consent Form [Part B] I have read, understood and agree to the Conditions of Entry and Tour Rules [Part D] and, if selected for
StuditaliA, agree to comply with these rules I have read the Queensland Code of School Behaviour and, if selected for StuditaliA, agree to abide by the code I am an Australian citizen, permanent resident of Australia, or New Zealand citizen residing in Australia I am available to travel from 19 November to 21 December 2017 I am medically fit for international travel, in accordance with the terms of cover under the Group Medical
Conditions (group policies) listed by GoSafe Travel Insurance , and will inform the organisers if my health changes such that I am not medically fit to travel
All information provided in this Student Application Form [Part A] is true and accurate to the best of my knowledge.
Applicant Signature Date
Applicant Name (please print)Parent/Guardian Signature Date
Parent/Guardian Name (please print)
Relationshipto applicant
CHECKLIST CONTACTCompleted: Student Application Form [Part A] ensuring any special
requirements are shown or indicated N/A in Section One Project Consent Form [Part B] Parent/Guardian’s Agreement Form [Part C]Have read: Conditions of Entry and Tour Rules [Part D]Attachments to be provided: Copy of passport photo page (if available) Copy of birth certificate (if you do not have a passport) Copy of most recent report cards (all subjects)
Ms Alessa GollerProject OfficerDET InternationalT (07) 3513 5710E [email protected]
Please email completed forms and attachments to [email protected]
Nominations close 5.00pm 28 April 2017
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