Bursary Application

Required Fields *

This application form is to be completed by the survivor and they must be working with a support agency to qualify.

I have read the Survivors Fund Application Overview from the link below.

Concord Survivors Fund Bursary Overview

STUDENT INFORMATION

*First Name

*Last Name

*Date of Birth

*Daytime Phone Number

*Email AddressUsed to email completed documents

Please double check that your email entered above is correct.

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<h1 style="font-weight: bold; font-size: 13pt; padding-top: 3pt; padding-left: 35pt; text-indent: 0pt; text-align: center;">Concord Adex Survivors Fund Bursary Application</h1>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: center;">Completed documents with advocates letter of support should be emailed to <a href="mailto:bursary@survivorsfund.ca">bursary@survivorsfund.ca</a></p>

<h3 style="font-weight: bold; text-decoration: underline; font-size: 13pt;">F. Student Information:</h3>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Please type or print your answers. If application is illegible, it will be returned to you as incomplete.</p>

<ul style="font-size: 12pt; line-height: 2.5; margin-top: 0; margin-bottom: 10px;">
 	<li style="padding-left: 10pt;">Last Name: {{last_name}}</li>
 	<li style="padding-left: 10pt;">First Name: {{first_name}}</li>
 	<li style="padding-left: 10pt;">Mailing Address: {{address_line_1}} {{address_line_2}}, {{city}}, {{province}}, {{postal_code}}</li>
 	<li style="padding-left: 10pt;">Daytime Telephone Number: {{daytime_phone_number}}</li>
 	<li style="padding-left: 10pt;">Email Address: {{email_address}}</li>
 	<li style="padding-left: 10pt;">Date of Birth (MM/DD/YYYY): {{date_of_birth}}</li>
</ul>
&nbsp;
<p style="font-family: Arial, sans-serif; font-weight: bold; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Applicants Educational Background</p>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Please include each high school attended within the section below. If additional space is needed, please list them on a separate piece of paper and attach to the application.</p>

<table style="width: 100%;">
<tbody>
<tr>
<td style="background-color: #f3f3f3;">Name(s) of High School Attended</td>
<td style="background-color: #f3f3f3;">High school Years Attended</td>
<td style="background-color: #f3f3f3;">High school Diploma Received</td>
</tr>
<tr>
<td>{{name_of_high_school_attended}}</td>
<td>{{highschool_years_attended}}</td>
<td>{{highschool_diploma_received}}</td>
</tr>
<tr>
<td>{{name_of_high_school_attended_2}}</td>
<td>{{highschool_years_attended_2}}</td>
<td>{{highschool_diploma_received_2}}</td>
</tr>
<tr>
<td>{{name_of_high_school_attended_3}}</td>
<td>{{highschool_years_attended_3}}</td>
<td>{{highschool_diploma_received_3}}</td>
</tr>
</tbody>
</table>
&nbsp;
<p style="font-family: Arial, sans-serif; font-weight: bold; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Applicant’s Post Secondary Background</p>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Please include each post secondary school attended within the section below. If additional space is needed, please list them on a separate piece of paper and attach to the application.</p>

<table style="width: 100%;">
<tbody>
<tr>
<td style="background-color: #f3f3f3;">Name(s) of Post-Secondary Institution Attended</td>
<td style="background-color: #f3f3f3;">Year Began</td>
<td style="background-color: #f3f3f3;">Year Ended</td>
<td style="background-color: #f3f3f3;">Year Graduated</td>
<td style="background-color: #f3f3f3;">Type of Certificate Diploma Degree Received</td>
</tr>
<tr>
<td>{{name_of_post_secondary_institution}}</td>
<td>{{post_secondary_year_began}}</td>
<td>{{post_secondary_year_ended}}</td>
<td>{{post_secondary_year_graduated}}</td>
<td>{{post_secondary_type_of_certificate_diploma_degree_received}}</td>
</tr>
<tr>
<td>{{name_of_post_secondary_institution_2}}</td>
<td>{{post_secondary_year_began_2}}</td>
<td>{{post_secondary_year_ended_2}}</td>
<td>{{post_secondary_year_graduated_2}}</td>
<td>{{post_secondary_type_of_certificate_diploma_degree_received_2}}</td>
</tr>
<tr>
<td>{{name_of_post_secondary_institution_3}}</td>
<td>{{post_secondary_year_began_3}}</td>
<td>{{post_secondary_year_ended_3}}</td>
<td>{{post_secondary_year_graduated_3}}</td>
<td>{{post_secondary_type_of_certificate_diploma_degree_received_3}}</td>
</tr>
</tbody>
</table>
&nbsp;
<p style="font-family: Arial, sans-serif; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;"><span style="font-weight: bold;">Current Employer and Current Occupation (if applicable):</span> {{current_employer_and_current_occupation}}</p>
&nbsp;
<h3 style="font-weight: bold; text-decoration: underline; font-size: 13pt;">G. Institution(s) Applied To:</h3>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Please fill in the information below regarding the educational program(s) for which you are seeking the Bursary. If applications were submitted to multiple institutions, please use the space provided below or list on a separate piece of paper and attach to the application.</p>

<table style="width: 100%;">
<tbody>
<tr>
<td style="background-color: #f3f3f3;">Name of Institution</td>
<td style="background-color: #f3f3f3;">Address of Institution</td>
<td style="background-color: #f3f3f3;">Area of Study or Program Name</td>
<td style="background-color: #f3f3f3;">Length of Program</td>
<td style="background-color: #f3f3f3;">Estimated Cost of Annual Tuition</td>
<td style="background-color: #f3f3f3;">Date of Application to the Program</td>
<td style="background-color: #f3f3f3;">Date you Expect to Receive Confirmation</td>
<td style="background-color: #f3f3f3;">Student #</td>
</tr>
<tr>
<td>{{name_of_institution}}</td>
<td>{{address_of_institution}}</td>
<td>{{area_of_study_or_program_name}}</td>
<td>{{length_of_program}}</td>
<td>{{estimated_cost_of_annual_tuition}}</td>
<td>{{date_of_application_to_the_program}}</td>
<td>{{date_you_expect_to_receive_confirmation}}</td>
<td>{{student_number}}</td>
</tr>
<tr>
<td>{{name_of_institution_2}}</td>
<td>{{address_of_institution_2}}</td>
<td>{{area_of_study_or_program_name_2}}</td>
<td>{{length_of_program_2}}</td>
<td>{{estimated_cost_of_annual_tuition_2}}</td>
<td>{{date_of_application_to_the_program_2}}</td>
<td>{{date_you_expect_to_receive_confirmation_2}}</td>
<td>{{student_number_2</td>
</tr>
</tbody>
</table>
&nbsp;
<p style="font-family: Arial, sans-serif; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">ADDRESS WHERE BURSARY CHEQUE SHOULD BE MAILED TO:</p>

<ul style="font-size: 12pt; line-height: 2.5; margin-top: 0; margin-bottom: 10px;">
 	<li style="padding-left: 10pt;">Attention Of: {{cheque_attention_of}}</li>
 	<li style="padding-left: 10pt;">Mailing Address: {{cheque_address}}, {{cheque_city}}, {{cheque_province}}, {{cheque_postal_code}}</li>
 	<li style="padding-left: 10pt;">Phone Number: {{cheque_phone_number}}</li>
</ul>
<p style="font-family: Arial, sans-serif; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Please note that proof of acceptance, a schedule of fees to your program of choice, your assigned student number, and name of payee at the institution to whom funds are to be dispersed are required before a bursary will be approved by the Committee.</p>

<h3 style="font-weight: bold; text-decoration: underline; font-size: 13pt;">H. Human Trafficking Support Group or Agency:</h3>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">All applicants must be working with a recognized group or agency which supports survivors of human trafficking. Please provide the following information regarding the agency you are involved with:</p>

<ul style="font-size: 12pt; line-height: 2.5; margin-top: 0; margin-bottom: 10px;">
 	<li style="padding-left: 10pt;">Name of Agency: {{name_of_agency}}</li>
 	<li style="padding-left: 10pt;">Address of Agency: {{address_of_agency}}</li>
 	<li style="padding-left: 10pt;">Length of Time Working with the Agency: {{length_of_time_working_with_the_agency}}</li>
 	<li style="padding-left: 10pt;">Name of Caseworker: {{name_of_caseworker}}</li>
 	<li style="padding-left: 10pt;">Caseworker’s Phone Number: {{caseworkers_phone_number}}</li>
</ul>
&nbsp;
<p style="font-family: Arial, sans-serif; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Does the applicant provide consent for the Committee to speak with the Caseworker? If yes, please sign the attached Consent Form.</p>

<h3 style="font-weight: bold; text-decoration: underline; font-size: 13pt;">I. Personal Essay:</h3>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Each applicant must complete a personal essay answering the following questions:</p>
<p style="font-family: Arial, sans-serif; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">1. Provide a brief description of yourself, your preferred area of study, and your career-related goals:</p>
{{provide_a_brief_description_of_yourself}}
<p style="font-family: Arial, sans-serif; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">2. Describe where you see yourself in 5 years. Please include the steps you would take to achieve this vision and how your life would be positively impacted if you were a recipient of this bursary. Submit your response on a separate sheet and attach to this application. Please limit to 500 words in total.</p>
{{describe_where_you_see_yourself_in_5_years}}
<h3 style="font-weight: bold; text-decoration: underline; font-size: 13pt;">J. Completing your Application:</h3>
<p style="font-family: Arial, sans-serif; font-style: italic; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">The following items must be attached to this application in order for the application to qualify for review by the Committee. Please circle "YES" or "NO" to be sure you have attached each item as required:</p>

<ul style="font-size: 12pt; line-height: 2.5; margin-top: 0; margin-bottom: 10px;">
 	<li style="padding-left: 10pt;">Letter of Support provided by your agency caseworker (additional letters of support may be provided, if desired):   YES    NO</li>
 	<li style="padding-left: 10pt;">Personal Essay addressing both questions, including: 1) A description of yourself, your preferred area of study, and your career-related goals, and 2) a description of where you see yourself in 5 years, including the steps you would take to achieve this vision and how your life would be positively impacted if you were a recipient of this bursary:   YES    NO</li>
</ul>
&nbsp;
<p style="font-family: Arial, sans-serif; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Please note that your application will be returned to you as incomplete if these items are not attached to this application.</p>
&nbsp;
<h1 style="font-weight: bold; font-size: 13pt; padding-top: 3pt; text-indent: 0pt;">STATEMENT OF ACCURACY</h1>
&nbsp;
<p style="padding-left: 5pt; text-indent: 0pt; text-align: justify;">I hereby affirm that all the above stated information provided by me is true and correct to the best of my knowledge. I also consent that some information related to the bursary (such as data related to programs of study, not including identifying information such as name or contact info) may be used for any purpose deemed necessary to promote the Concord Adex Survivors’ Fund. I understand that the Fund will not use my name and contact information for the purposes stated above without my permission.</p>
<p style="padding-left: 5pt; text-indent: 0pt; text-align: justify;">I hereby understand that if chosen as a bursary recipient, I must provide evidence of enrollment/registration in an accredited post-secondary institution, before bursary funds will be transferred.</p>
&nbsp;
<table>
<tbody>
<tr style="height: 80px;">
<td width="350">Signature of Bursary Applicant: <span style="font-size: 12pt; background-color: #ff0; border-bottom: 1px solid #000; vertical-align: bottom;">X
</span></td>
<td width="200">Dated: <span style="font-size: 12pt; background-color: #ff0; border-bottom: 1px solid #000; vertical-align: bottom;">
</span></td>
</tr>
</tbody>
</table>
</div>
&nbsp;

&nbsp;

&nbsp;
<div style="color: black; font-family: Arial, sans-serif; font-style: normal;">
<p style="padding-left: 14pt; text-indent: 0pt; text-align: left;"><img src="https://www.survivorsfund.ca/wp-content/uploads/2021/02/SurvivorsFund-LOGO-90.png" alt="" width="90" height="90" /></p>

<h1 style="font-weight: bold; font-size: 13pt; padding-top: 3pt; padding-left: 35pt; text-indent: 0pt; text-align: center;">TO BE COMPLETED BY THE APPLICANT'S ADVOCATE</h1>
<h1 style="font-weight: bold; font-size: 13pt; padding-top: 3pt; padding-left: 35pt; text-indent: 0pt; text-align: center;">Concord Adex Survivors Fund Letter of Support</h1>
<p style="font-family: Arial, sans-serif; font-weight: normal; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;"><strong>Guidelines</strong></p>
Applicants for a bursary must have a support worker assisting them to exit human trafficking. Their support worker must complete a Letter of Support for the applicant as part of their application for a bursary.
The committee relies heavily on the support worker’s professional opinion, in the Letter of Support, to come to its decision about whether or not to award a bursary.
The committee is most interested in an applicant’s readiness to take on the challenges of education and/or vocational training, as well as a demonstrated financial need. The questions below assist in determining the applicant’s chances of success in their pursuit of an education. The committee would like concrete examples of the applicant’s progress in exiting human trafficking.
<p style="font-family: Arial, sans-serif; font-weight: bold; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Part A. Support Worker:</p>
Name:

Job Title:

Area(s) of Focus:

Is the applicant a survivor of human trafficking?

How long have you been working with the applicant?

Do you expect to continue to support the applicant while they are in school?

&nbsp;
<p style="font-family: Arial, sans-serif; font-weight: bold; text-decoration: none; font-size: 12pt; padding-top: 2pt; padding-left: 5pt; text-indent: 0pt; line-height: 114%; text-align: left;">Part C. Recommendation:
<em>Please provide your opinion as to the applicant's likelihood of success in pursuing an education. Please try to address the questions listed below:</em></p>

<ol>
 	<li style="padding-bottom: 25px;">What makes this applicant a good candidate for a bursary?</li>
 	<li style="padding-bottom: 25px;">Why do you think that the applicant is ready to pursue education or vocational training?</li>
 	<li style="padding-bottom: 25px;">What are the barriers to the applicant’s success in school?</li>
 	<li style="padding-bottom: 25px;">What support does the applicant have to help them succeed in school?</li>
 	<li style="padding-bottom: 25px;">What financial constraints make this bursary a good option for the applicant?</li>
</ol>
</div>

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Bursary Application

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RESTAURANTS

List of participating restaurants will be available February 1st, 2022.

Valentine's Live Event

Get Ready!

The video link will be available Monday February 14th at 5:00 pm local time.

Bursary Application

1 IF any all of these conditions are true

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ELSE

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ELSE

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5IF any all of these conditions are true

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RESTAURANTS

List of participating restaurants will be available February 1st, 2022.

Valentine's Live Event

Get Ready!

The video link will be available Monday February 14th at 5:00 pm local time.

1
IF of these conditions are true

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