Amy Levai Aboriginal teaching scholarship preservice application

Section 1: personal details

Family name:		Click here to enter text.	Given name:		Click here to enter text.
Date of birth:		Click here to enter text.	Gender:		☐ Female ☐ Male
Home phone:		Click here to enter text.	Mobile phone:		Click here to enter text.
Home address:		Click here to enter text.
Suburb/Town:		Click here to enter text.		Postcode:		Click here to enter text.
Postal address:		Click here to enter text.
Suburb/Town:		Click here to enter text.		Postcode:		Click here to enter text.
Email address:		Click here to enter text.
	Attach a copy of your birth certificate.

Section 2: verification of Australian Aboriginal heritage

To be eligible you must be Australian Aboriginal and/or Torres Strait Islander.
Indicate your heritage:		Choose an item.
	Attach a copy of your verification of Aboriginal and/or Torres Strait Islander heritage. Ensure this is a document executed by an Aboriginal or Torres Strait Islander Organisation and endorsed with a Common Seal.

Section 3: academic details

Indicate your current tertiary academic status.
☐ I am enrolled in a teacher education program.
☐ I have applied to commence in a teacher education program next year.
Insert the teacher education program you are currently enrolled in or the program/s for which you intend to enrol (in priority order).
Program name		Tertiary institution		Expected completion (MM/YYYY)
Click here to enter text.		Click here to enter text.		Click here to enter text.
Click here to enter text.		Click here to enter text.		Click here to enter text.
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	Attach a copy of your SATAC letter (or send when available) or Attach copies of all your academic transcripts and professional experience reports to date
Indicate whether you are, or intend to study full time or part time.			☐ Full time ☐ Part time
Indicate your current or anticipated study load per semester eg how many units/subjects per semester are/will you study?			Click here to enter text. units per semester

If you are, or will be studying with at an interstate university, please ensure your teacher education program will meet the requirements for teacher registration in South Australia.
I have checked with the Teachers Registration Board of South Australia and confirm my teacher education program will meet the requirements for teacher registration in South Australia.	☐ Yes ☐ Not applicable

Section 4: level of schooling

Indicate the level/s of schooling you will be qualified to teach as identified by the program you are, or will be studying.
☐ Secondary (Year 8-12)	☐ Middle/Secondary (Year 6-12)	☐ Middle School (Year 6-9)
☐ Primary/Middle (Year 3-9)	☐ Primary (Year 3-7)	☐ Junior Primary/Primary (Year R-7)
☐ Junior Primary (Year R-2)	☐ Early Childhood (B-8 years, inclusive of preschool and junior primary)	☐ Other (please elaborate) Click here to enter text.

Section 5: teaching subjects (secondary and/or middle school)

Complete this section only if you have indicated you will qualify to teach secondary and/or middle school. To increase your employability as a teacher with the Department for Education and Child Development, it is strongly recommended that your subject major and minor come from two different domains/teaching areas as identified in DECD teaching subject and skill code. Employability is determined by the way schools describe teacher vacancies, with the most common preference for two different domains/teaching areas. Not all subjects included in teacher education programs correspond with specific subjects taught in schools. While it is good to study subject areas of interest, participation in the scholarship program requires that you maximise your employability. If you are unsure whether your subject choices align with DECD teaching subjects, contact 8226 1456 or [e-mail] to discuss. Studying in one domain/teaching area only may influence your scholarship eligibility. Applications will be assessed on an individual basis taking into consideration how your subject choices align with DECD teaching subjects.

Indicate below: the subjects you are studying or intend to study in your teacher education course the level of your study in each area and alignment with DECD domains/subjects (refer to DECD teaching subject and skill code) Major (minimum of 6 x semester courses in a specialist subject) will allow you to teach to Year 12; or Minor (minimum of 4 x semester courses in a specialist subject) will allow you to teach to Year 10

Domain: Click here to enter text. Subject: Click here to enter text. ☐ Major (to Year 12) OR ☐ Minor (to Year 10)

Domain:Click here to enter text. Subject: Click here to enter text. ☐ Major (to Year 12) OR ☐ Minor (to Year 10)

Domain:Click here to enter text. Subject: Click here to enter text. ☐ Major (to Year 12) OR ☐ Minor (to Year 10)

Section 6: location preferences

In South Australia all DECD schools and preschools are grouped under 20 portfolios. Each portfolio consists of 2, 3 or 4 partnerships. Local partnerships are geographical localities consisting of schools and preschools within close proximity. There are opportunities for employment in metropolitan and country locations. Indicate your location preference/s below and then select the required number of metropolitan or country portfolios (partnerships) in priority order.
☐ Country only There are 8 country based portfolios. A minimum of 6 portfolios are required from the drop down lists following.	☐ Metropolitan only There are 12 metropolitan based portfolios. All 12 portfolios are required from the drop down lists following.	☐ Metropolitan and country There are a total of 20 based metropolitan and country based portfolios. A minimum of 13 portfolios are required from the drop down lists following.

1	Click to select preference
2	Click to select preference
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5	Click to select preference
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19	Click to select preference
20	Click to select preference

Section 7: employment history

Complete details of previous employment (if applicable).
Employer	Permanent/temporary	Employment dates
Click here to enter text.	Click here to enter text.	Click here to enter text.
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Click here to enter text.	Click here to enter text.	Click here to enter text.

Section 8a: referees

Provide details of two referees. Year 12 students: your referees must be your current secondary teachers. Other: your referees must be able to provide comment on your capabilities and commitment to becoming a teacher. For current university students this may (if applicable) include a university supervisor or professional experience supervisor. Your first referee is required to provide a statement in support of your application.
Referee 1		Referee 2
Name:	Click here to enter text.	Name:	Click here to enter text.
Position held:	Click here to enter text.	Position held:	Click here to enter text.
Organisation:	Click here to enter text.	Organisation:	Click here to enter text.
Relationship to applicant:	Click here to enter text.	Relationship to applicant:	Click here to enter text.
Telephone:	Click here to enter text.	Telephone:	Click here to enter text.
Email:	Click here to enter text.	Email:	Click here to enter text.

Section 8b: referee 1 statement

Please discuss your comments with the applicant.
Provide comments relating to the applicant’s personal skills, ability and commitment to becoming a teacher. Click here to enter text.
Referee Signature:			Date:
Referee Name:	Click here to enter text.
For any queries, contact Susie Stevens, Project Manager 8226 1456 or [e-mail].

Section 9: applicant’s supporting statement

Maximum length of one A4 page only.

Please outline your commitment to becoming a teacher in the public education system (include skills and strengths that you would bring to a public school and the local school community). Click here to enter text.

Section 10: additional requirement

In support of your application, you may be required to participate in further activities, including a conversational interview.
I accept the requirement described above.	☐ Yes ☐ No

Section 11: other information

	All questions must be answered (YES or NO) in this section. If you answer YES to any of the below questions, you are obliged to provide comprehensive supporting details, including any relevant documentation. Provide full details, including dates on a separate sheet marked ‘Confidential’. Please note that these are the same questions asked of all teachers seeking employment with the Department for Education and Child Development. In the event that any further medical information is required, you may be invited to provide management in DECD with authority to seek medical information from any treating medical practitioner/s or from an independent medical practitioner/s. You will be personally liable for any cost associated with ascertaining any further medical information. Please note that answering YES to any question, does not automatically exclude you from being considered for inclusion in an Aboriginal Teacher Employment Program.
Have you ever been investigated, arrested, reported for or pleaded or found guilty of any criminal offence, including any traffic offences?		☐ Yes ☐ No
Have you ever been the subject of allegations of conduct by you of a violent and/or sexual nature towards or in relation to a child or children (person under 18 years of age) or an adult (person over 18 years of age)?		☐ Yes ☐ No
Have you ever been the subject of allegations or an investigation or any other process relating to alleged unsatisfactory performance or misconduct by you as an employee?		☐ Yes ☐ No
Do you suffer from or have you suffered from any psychological or medical condition/s, illness/es, disability/ies, restriction/s, or any learning disability/ies that may affect your ability to carry out the duties of the role you apply for?		☐ Yes ☐ No
Are you taking or consuming any prescription medication/s or other substance/s that may affect your ability to perform the duties of the role applied for or give rise to a risk to your health or safety in the workplace or that of other persons?		☐ Yes ☐ No
Have you ever submitted a claim for workers compensation (whether accepted or proven or not)? NB: If you answer yes also give full details of any redemption payouts.		☐ Yes ☐ No
Would you require any special services, support and/or facilities and/or reasonable workplace modifications in order for you to perform the inherent requirements of the duties of the role you apply for?		☐ Yes ☐ No
Have you at any time resigned from public sector employment upon accepting a ‘Changing Directions’ incentive payment or a Targeted Voluntary Separation Package or any other form of redundancy or separation payment?		☐ Yes ☐ No
Have you been dismissed from any previous employment - for any reason (including but not limited to redundancy)?		☐ Yes ☐ No
Have you ever resigned from any previous employment, including by retirement?		☐ Yes ☐ No

Are you currently in receipt of funds from any other DECD, State Government or Australian Government scholarship?	☐ Yes ☐ No
If yes, please provide details: Click here to enter text.
How did you find out about the Amy Levai Aboriginal Teaching Scholarship?
Click here to enter text.

Section 12: applicant declaration

I confirm and declare that to the best of my knowledge, the information in this application is true and correct and acknowledge that any wilful suppression or inaccuracy may render me ineligible for consideration or inclusion in an Aboriginal Teacher Employment Program. I understand that information provided by me will be available to DECD staff for the purpose of identifying successful applicants for inclusion in an Aboriginal Teacher Employment Program. If I am successful for inclusion in an Aboriginal Teacher Employment Program, I agree to abide by the contractual agreement and accept that any employment gained following the successful completion of a teacher education program, will be in accordance with employment conditions stated in DECD policy for the Recruitment and selection of teaching staff in the schools.
Applicant’s signature:			Date:         /          /
Parent/Guardian (if under 18 years)			Date:         /          /

Please provide any additional comments in support of your application.

Click here to enter text.

APPLICATION CHECKLIST
☐	I have completed all sections of the application including the Supporting Statement (Section 9).
☐	My first referee has provided a statement in support of my application (Section 8b).
☐	I have advised both referees they may be contacted.
☐	I have retained a copy of this application for my records.

DOCUMENT CHECKLIST
	It is essential ALL relevant paperwork is attached to your application.
☐	Birth certificate
☐	Verification of Aboriginal and/or Torres Strait Islander heritage (document endorsed with a Common Seal by an Aboriginal or Torres Strait Islander Organisation).
☐	SATAC letter (this relates to your official acceptance into a teacher education program and can be submitted once you have been accepted into a program). Please indicate your status if this is not attached. Click here to enter text.
☐	SATAC results and/or academic transcripts of all current and completed studies
☐	Professional Experience reports (for students who have undertaken professional experience placements experience/s as part of their teacher education program).

Applications can be submitted at any time (students applying for the scholarship in their final year of study must submit an application by 31 May of that year).

Complete and forward your application, along with scanned attachments to [e-mail].

Further information direct enquiries to:

Phone: [phone]

Email: [e-mail]

| Amy Levai Aboriginal teaching scholarship application | November 2016