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REACH - Realising Educational Aspirations for Careers in Health

Programme dates: Will be held early August each year
Application opening date: 12pm 26 Feb
Application closing date: 5pm 15 June

Fields marked with an * must be completed.

Applicants details Family name* Given name(s)* Date of birth
_(dd/mm/yyyy)* Current NCEA year level* Gender*

Home address

Number and street* Suburb* Town or city* Postcode*

Postal address

Same as home address

Number and street* Suburb* Town or city* Postcode*

Mobile number* Home number* Email address* Ethnicity* Iwi affiliations* Hapū Marae

If you are living in a boarding school please provide the name, address and phone number of the Hostel Manager Name Address Telephone number

Do you have any medical and/or dietary and/or access requirements?
_{Please indicate any medical conditions, dietary requirements or
special circumstances which the organisers should be aware of and
what precautions need to be taken (e.g asthma, heart condition,
allergies).}

Parent/legal guardian contact details Surname* First name* Relationship to you* Address (number and street)* Suburb* Town or city* Postcode* Mobile* Home* Email address*

Academic details NSN number* School currently attending*

Level 2 subjects	Credits attained

Current subjects (year 13)

Scholarships/programmes you are involved in

University of Otago:: Hands on Science, Science Wānanga, OUASSA, OCE or any other Otago programmes
University of Auckland:: Whakapike Ake: MASH or COACH programmes
DHB Initiatives:: Kia Ora Hauora, Incubator or any other initiatives

Programme	Location	Date attended

Personal statement* Please provide a personal statement telling us about you and your interest in a career in health (500 words max)

Written essay questions 1. Please explain how this scholarship would benefit you and/or your family (200 words) 2. Describe your involvement and/or interest in Te Ao Māori eg marae experience, Te Reo Māori, kapa haka etc. (200 words max)

What best describes you in relation to University study? (Please tick all that apply to you)

No one in my immediate family has ever been to university No one in my extended family has ever been to university I have sibling(s) in university study but they are the first generation One or both of my parents went to university My parents and siblings have not attended university but I have extended family who have

Confidential reference

Please provide details of at least one but up to two confidential referees who can comment on your academic ability and/or commitment to Māori health and Te Ao Māori. At least one referee should be your School Principal or Associate/Deputy/Assistant Principal or Year 13 Dean. A confidential reference form will be emailed to your referee(s) to complete and return.

Referee #1*

Full name Email address Telephone

Referee #2

Full name Email address Telephone

Privacy statement

The information requested in this application form and your academic record will be used for the purposes of assessing your application for the REACH Scholarship. Information may also be used for statistical purposes. This potential use would aggregate data and therefore not identify individual applicants.

The University of Otago undertakes to store your application in a secure place in the event that you are successful in gaining entry to REACH. In the event that you are unsuccessful, we will retain the application and details in order to provide other potential scholarship opportunities to you in the future. References provided by third parties relating to your application are confidential, and you will not be permitted to access these reports.

Successful applicants agree to co-operate with any publicity relating to the REACH Scholarship.

I have read and understood the privacy statement above and agree to its conditions.*

Declaration of applicant I confirm that all the information supplied and attached to this form is true and correct.* I am aware that incomplete or late applications will not be considered for selection.* I confirm that the information provided has been written by me.* I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the terms and conditions of this application.* I am aware that it is my responsibility to ensure my referee(s) submit a confidential reference by 15 June.*

Ask OtagoPātai ki Otāgo
0800 80 80 98
64 3 479 7000
university@otago.ac.nz

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