Kelsey Basic Education Student Awards Application Form

BASIC EDUCATION APPLICATION FORM
KELSEY CAMPUS
Deadline: 4:30 pm, May 31st, 2013
Student Name: _______________________________ SIAST I.D. Number: ____________________
Current Program: ___________________________________________________________________
Listed below are all the scholarships and bursaries for which you may apply using this form.
Check ONLY the boxes of those awards for which you are applying.
Consult the information included in this application to ensure you meet the eligibility
requirements.
Other scholarships, bursaries and awards may be available at
http://www.siast.sk.ca/admissions/scholarships_awards.shtml
Please ensure you complete all sections of the application required by the
award(s) for which you are applying, and include any attachments.
INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED FOR SELECTION
John Norris Saskatchewan Advantage Opportunity and Innovation Memorial Scholarship
John Stratychuk Saskatchewan Advantage Opportunity and Innovation Memorial Scholarship
Kelsey Campus Basic Education Business Saskatchewan Advantage Opportunity and
Innovation Scholarship
Kelsey Campus Basic Education Industry Saskatchewan Advantage Opportunity and Innovation
Scholarship
Kelsey Campus Basic Education Student Leadership Award (Grade 10)
Kelsey Campus Basic Education Student Leadership Award (Grade 12)
Submit this application with all supporting documentation to:
Amanda Hussey
Donor & Alumni Relations Office
SIAST Wascana Campus
4500 Wascana Parkway
Regina SK S4P 3A3
Phone: 306-775.7716
Fax: 306-798-8113
Email: Amanda.hussey@siast.sk.ca
SIAST reserves the right to make whatever changes circumstances may require, including
cancellation of particular awards.
Only successful recipients are notified.

As a condition of acceptance, recipients must give permission to SIAST to provide their contact
information to the donor of the award and consent to publication of their name and program in SIAST’s
awards programs, and/or used in other media outlets or SIAST publications.
Last Name
Mailing Address
Phone #
PERSONAL INFORMATION – MUST PROVIDE ALL INFORMATION
Cell #
SIAST Campus Attending Program
Conditions of Acceptance
First Name SIAST ID Number
City/Province Postal Code
Email:
__________________________________
Adult Basic Education
10 12
Other _____________________________
STUDENT DECLARATION – MUST BE COMPLETED
Course Load
Full time Part time
On-Line
Full time Part time
Full time = 60% of full time class load
This personal information is being collected under the authority of The SIAST Act, 1996, and is protected by The Local Authority
Freedom of Information and Protection of Privacy Act. It will be used for the purposes of award selection and administration and
will be shared with selection committee members. This personal information may also be used for administrative and statistical
purposes by SIAST and/or provincial or federal government ministries and agencies. If selected, recipients’ names, program of
study, may be disclosed to the donor of the award, and published in SIAST’s awards programs, and/or used in other media
outlets or SIAST publications. Recipients will be required to give permission to SIAST to provide their contact information to the
donor of the award if requested by the donor.
By signing this document I declare:
I have read and agree to the Conditions of Acceptance. I declare that the information I have given is true and reflects an
accurate summary of my financial information and that I have answered all questions applicable to me. If at any time I no longer
meet award criteria, due to withdrawal or other reasons, payment will be withheld. I understand that the values and availability of
awards, policies and procedures regarding that administration of awards may change at the Donor’s or SIAST’s discretion.
Signature of Student: _______________________________________ Date: ________________________
1. EDUCATION EQUITY STUDENTS
(if selected you may be required to provide supporting documentation)
Aboriginal ancestry (Indian, Métis, Inuit) Visible Minority
Women in non-traditional trades Disability

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3. ADDITIONAL INFORMATION
Complete ONLY the sections which are required by the selection criteria for the awards for which you are
applying.
Please be specific and attach additional pages if necessary.
VOLUNTEERISM - SIAST AND/OR HIGH SCHOOL
List activities and/or positions held
VOLUNTEERISM - COMMUNITY
List activities and/or position(s) held
ATHLETIC ACTIVITIES
List activities and/or positions held
LEADERSHIP ACTIVITIES
(List and describe leadership roles on campus, in high school and/or in the community)
CAREER GOALS

ATTACHMENTS
Attach ONLY the items which are required by the selection criteria for the awards for which you are applying
TRANSCRIPT
English A30 *
English B30 *
Required Subjects Mark % Grade
Social Studies or Native Studies or History 30* (please specify)
Science (highest mark)
(please specify: Chemistry, Biology, Physics 20 or 30)*
Math (highest mark)
(please specify: Math A30, Math B30, Math C30) *
Add up marks received and divide by 5 to get your average
mark.
_______________%
* Or Grade 10 equivalent for Grade 10 students
Note: If student is currently enrolled in class, a mid-term mark should be indicated.
By applying for awards, students consent to the use and disclosure of their personal information as described above.
If you have any questions or concerns about the collection or disclosure of this personal information, contact SIAST
Admin Office (306) 659-3733.
Submit this application with all supporting documentation to:
SIAST Wascana Campus
Amanda Hussey
4500 Wascana Parkway
Phone: 306-775-7716
Email: amanda.hussey@siast.sk.ca
SIAST reserves the right to make whatever changes circumstances may require, including
cancellation of particular awards.
Only successful recipients are notified.

Kelsey 2012 Spring Basic Education Application Guide
Award name Value # Available Program Eligibility Selection Criteria
John Norris Saskatchewan
Advantage Opportunity and
Innovation Memorial Scholarship
John Stratychuk Saskatchewan
Advantage Opportunity and
Innovation Memorial Scholarship
Kelsey Campus Basic Education
Business Saskatchewan
Advantage Opportunity and
Innovation Scholarship
Kelsey Campus Basic Education
Industry Saskatchewan
Innovation and Opportunity
Scholarship
Kelsey Campus Basic Education
Student Leadership Award
Kelsey Campus Basic Education
Student Leadership Award
$600.00 2 Adult 12
$600.00 2 Adult 12
$600.00 1 Adult 12
$600.00 1 Adult 12
$300.00 1 Adult 12
$300.00 1 Adult 10
Be enrolled full-time in the Adult 12 program at SIAST Kelsey campus
(minimum 2 semesters); Applicants must show proof of enrollment in a
math or science based program at any accredited post secondary
institution (i.e.: Biotechnology, Chemical Technology, Cytotechnology).
Be enrolled full-time in the Adult 12 program at SIAST Kelsey campus
(minimum 2 semesters). Applicants must show proof of enrollment in a
community services program at any accredited post-secondary
institution (i.e.: Early Childhood Education, Addictions Counseling,
Youth Care Worker).
Be enrolled full-time in the Kelsey Adult 12 program (minimum of 2
semesters); Show proof of acceptance into a business program at any
accredited institution (i.e.: Accounting, Administration, Human
Resources).
Be enrolled full-time in the Kelsey Adult 12 program (minimum of 2
semesters); Show proof of acceptance into an industrial program at any
accredited institution (i.e.: Auto Body, Machine Shop, Welding).
Be enrolled full-time in the Basic Education Adult 12 program at SIAST
Kelsey campus (minimum of 2 semesters).
Be enrolled full-time in the Basic Education Adult 10 program at SIAST
Kelsey campus (minimum of 2 semesters).
Academic Achievement (100% weighting).
Academic Achievement (100% weighting).
Academic Achievement (100% weighting).
Academic Achievement (100% weighting).
Leadership - Program and class (40% weighting);
Volunteerism - SIAST Kelsey campus including
program and class (40% weighting); Academic
Achievement (20% weighting).
Leadership - Program and class (40% weighting);
Volunteerism - SIAST Kelsey campus including
program and class (40% weighting); Academic
Achievement (20% weighting).

2.FINANCIALINFORMATION(asofapplicationdateforcurrentacademicyear)
INCOME
Monthly Income including: Other Income:
Band, Indian/Northern Affairs, or other agency
Employment income (per month) - while attending school $
sponsored funding for tuition, books, and supplies $
Student or personal loans, or loans/funding from
parent(s)/relative(s) - Use total amount approved $
Spouse's monthly income $
Total amount of savings before school starts (before
tuition paid) $
Monthly income from Band, Indian/Northern Affairs or
other sponsoring agency $
Scholarships, Bursaries, Awards, and Grants confirmed
Monthly child support or alimony $
prior to this application date $
Other monthly income - EI, WCB, PTA, etc. $ Total of other income $ B
Total of income per month - add lines 1 - 5 $
Number of months in your program X
Total of Monthly Income in this school year $ A A+B $ C
EXPENSES
Monthly Living Allowance - Select one only Tuition, Books, and Supplies:
Single student living at home - $450 $ Tuition - please use actual amount $
Single student living away from home - $1000 $ Books and supplies - $3,000 maximum $
Single parent with child(ren) - $1,300 $ Total of tuition, books, & supplies $ E
Married student and spouse - $1,900 $
Allowance for Dependents D+E $ F
Allowance per child - $500 X___ # of dependents $
Additional expenses for dependents 11 and under
SubsidizedChildCare
In subsidized Child Care - $100 X ___ # of dependents $ ENTERAMOUNTSFROMLINESABOVE
Nonsubsizedchildcare C $
$400 for the first child 11 or younger $
$150 for every other child 11 or younger ($150 X ___) $ F $
Total of expenses per month - add expense lines above $ FINANCIALNEED
Number of months in your programX Ifyourfinancialneedispostive(CislargerthanF)put0
Total of Monthly Expenses in this school year $ D CminusF(CF) $