Applicant DetailsName(Required) Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Prefix First Last Postal Address(Required) Street Address Address Line 2 City Australian Capital TerritoryNew South WalesNorthern TerritoryQueenslandSouth AustraliaTasmaniaVictoriaWestern Australia State Postcode Phone(Required)Email(Required) ACA Member Number (if applicable)EligibilityEligibility Criteria(Required) of Aboriginal and/or Torres Strait Islander descent and Australian resident (applicants must identify as and be able to provide a confirmation of their Aboriginal and/or Torres Strait Islander status) enrolled or accepted into an entry level or graduate entry level chiropractic course (supporting documents will need to be provided - funding is now for postgraduate study) be a current member of or willingness to join the Australian Chiropractors Association be a current member of or willingness to join Indigenous Allied Health Australia Select AllTertiary InstitutionInstitution/Faculty/Department(Required)Selection CriteriaDescribe what has been your driving influence/motivation in wanting to become a chiropractor(Required)(up to 200 words)Discuss what you hope to accomplish as a chiropractor in the next 5-10 years(Required)(up to 200 words)Discuss your commitment to study in chiropractic(Required)(up to 200 words)Outline your involvement in community activities, including promoting the health and wellbeing of Aboriginal and Torres Strait Islander people(Required)(up to 200 words)How will the scholarship benefit you professionally, personally and culturally(Required)(up to 200 words)Selection CriteriaI declare that to the best of my knowledge the details provided in this application form and in any supporting documentation are true and complete. I am aware that there are severe penalties for providing false or misleading information, including exclusion of my application and cancellation of scholarship support. In applying for this scholarship, I hereby give consent for the application to be made available to others for purpose of providing peer review. If successful in this application I agree to abide by the conditions of award as stipulated in the ACA Scholarship Funding Agreement. Applicant(Required) First Last Signature(Required)Date(Required) DD slash MM slash YYYY
