DAVID WILLIAMS FUND ABN VAC: 52 907 644 835 CONFIDENTIAL ABN GMHC: 87 652 472 253

STUDY ASSIST REGISTRATION FORM 2024

The David Williams Fund provides support to improve the well-being of the Victorian HIV community. Not all applications are approved as demand on the fund is high.

The DWF Study Assist project accepts applications for: Enrolment Fees, books, Course equipment, and other relevant needs for further education

The fund cannot provide: HEX, HELP or VET debts, University loans, late fees from Libraries, fees / items already paid

The checklist on the back of this form will assist you to complete the application correctly. It may be to your advantage to access a community /social worker, to assist with your application.

Interviews: you may be required to attend an interview with the DWF coordinator to determine suitability. Entry requirements must be researched by the applicant and not the DWF’s responsibility.

All applications must be lodged by 4.00 pm Friday to 51 Commercial Rd South Yarra 3141. All applicants are advised of the outcome by email or phone during the following week.

As a publicly funded organisation we are bound by the Victorian privacy laws - the Information Privacy Act 2000 and the Health Records Act 2001 - as well as other laws which impose specific obligations on us in regard to handling information. Files are shredded if not used for seven years.

Legal Name*:
Preferred Name:
Address:
Postal add (if diff)
Date of Birth*:	Centrelink CRN:
Phone number:
Email address:
*Mandatory fields OR details via THH client file	
Case Worker Details (if applicable):
Name:	Phone:
Organisation:
How did you hear about Study Assit?
If you do not want mail sent, please mark this box:	

Office Use Only:

DWF#: _________________________

Verification of Health Status
Already uploaded to THH client file	
Attached to this Application	
Requested from Dr, will forward asap	
Verification of Centrelink / DHHS Benefits (if applicable)
Heathcare card already uploaded to THH client file	
Healthcare/SSRS card attached to this Application	
Income Statement attached to this Application	
Centrelink Authority attached to this Application	
Please call the client to arrange a verbal authority *You must make the client aware that we will call them	

General Statistical Information
The following information has been added to THH client file in its entirety	(no need to complete)
What year were you diagnosed with HIV?

Gender:

Agender		Male/Man		Questioning	
Female/Woman		Non-binary		Unspecified	
Gender Queer		PNTS	

Pronouns:

Sex assigned at birth:

Male		Female		PNTS		Unknown/Not Stated		Transgender	

Intersex:

Yes		No		PNTS		Unknown/Not Stated	

Sexual Orientation:

Asexual		Lesbian		Queer	
Bisexual		Not Specified		Questioning	
Gay		Pansexual	
Heterosexual		PNTS	

Origins:

Country of birth	Ethnicity
Speaks English?	Yes		No		Language spoken at home

ATSI Status:

Aboriginal		Neither A nor TSI	
A and TSI		Not Stated	
Torres Strait Islander	

Residency status:

Citizen		Permanent Resident	
Migrant		Asylum Seeker	
Refugee		In Progress	
Unknown	

Financial Information
Income
What kind of Centrelink / DHHS Benefit do you receive?
How much do you receive per fortnight?	$
Do you have any other income? What Type?
How much do you receive per fortnight?	$
Total fortnightly income from all sources:	$
Accommodation
Boarding House		Independent Unit in Retirement Village		Public Hsg - Transitional	
Couch surfing		Paying Board		Supported Accommodation	
Crisis/Emergency		Permanent Housing		Temporary	
Homeless		Prison / Remand / Detention		Transitioning	
Home Owner		Private Rental		Other:
Hostel		Public Hsg – Permanent	
Are you in shared accommodation? If so, how many do you share with?
How much do you pay per month?

Financial Counselling
Do you have financial concerns about any of the following?
Infringements / Fines		Gambling (self or others)	
Assets at Risk		Credit Debt	
Emergency Relief		Legal Action	
Overdue Utilities		Telco Debts	
Outstanding Bills		Rental Goods	
Afterpay		Payday Loans	
Other – Please specify:
Please give a brief description of your financial Issues:
This box will expand as you type
Current Debts – Only required if you need our Financial Counsellor to assist with these debts
Credit Card	Total amount outstanding:	$
Monthly Payments:	$
Personal Loan	Total amount outstanding:	$
Monthly Payments:	$
Centrelink Loan	Total amount outstanding:	$
Fortnightly Payments:	$
Mortgage	Total amount outstanding:	$
Monthly Payments:	$
Other:	Total amount outstanding:	$
Monthly Payments:	$

Course / University / Tafe Information

Name of Course:
Which education institution is your course at?

Is the course you are applying for accredited?	Yes		No	
If no, the DWF may not be able to assist, please check for accredited courses.
Are you applying for 1st year?	Yes		No	
If yes:
Have you attached confirmation verifying acceptance to the course?	Yes		No	
Are you applying for continuing study?	Yes		No	
If yes:
Have you attached verification / end of year reports, showing what you have already completed?	Yes		No	

Other Scholarships

Have you applied for any other scholarships / grants?	Yes		No	

If so, where and what was the outcome?
This box will expand as you type

Please note, you may also be required to apply for other scholarship / funding sources along with requesting our funding. It is advisable to have an interview with the David Williams Fund coordinator to ensure all options are open.

Request For Study Assistance

Do you know you can get free Microsoft office if you are a student? Just put your student email onto this site https://products.office.com/en-au/student/office-in-education

Item and payment information
Please note you may request multiple items but there is no guarantee that these will be granted. Please prioritise your requests. You may include study materials / fees / books and items related to your area of study. All cheques are to be made out directly to the TAFE / University / College or bookshops. Payments will not be made into your account.
Item:	Amount $:	Payable to:
1
2
3
Please eMAIL me the outcome		Please call me with the outcome	

Supporting Statement (required)
Please document below what you want to study and how it will improve your health / wellbeing and/or chances of employment. Please detail why you want to do this particular course of study. Attach a separate piece of paper if necessary: THIS PART IS MUST BE COMPLETED FOR THE APPLICATION TO BE PROCCESSED
This box will expand as you type

Client Consent Statement
I authorise the DWF to seek verification if and where necessary to confirm any information provided in this application or any applications I may make in the future. I certify that all the information provided is true and correct. I agree that the DWF may share and exchange information in order to assist in resolving my financial difficulties with other agencies / companies directly involved, for the purpose of providing me with the best possible support to suit my circumstances. I understand that relevant information about me will only be shared when deemed necessary or to progress my case or application and consent to my name, address and phone number being given to the DWF supplier. I certify that all the information provided is correct and true.
Client signature:	Date:
If prepared by Case Worker on the Client’s behalf:
Case worker’s name:	Phone:
Signature:	Date:

CHECKLIST

Please tick the appropriate boxes

If you haven’t attached the appropriate documentation your application will be delayed until the documentation has been provided

I have attached verification of my health status, from my doctor – All registration documents must be originals, not faxed or photocopies.

I have attached a current copy of my Centrelink Health care card

I have attached a copy of Centrelink income statement or I have signed authority for the Fund to obtain one (attached)

I have attached a copy of the course enrolment form, acceptance and invoice

I have attached information of other scholarships / grants if applicable

I have attended an interview with the David Williams Fund coordinator.

I have attached any other relevant information to enhance my application

If you wish the committee to reconsider your application because of special circumstances or if you are not satisfied with some aspect of the DWF process, you must put it in writing and forward it to the DWF committee.

David Williams Fund

ABN VAC 52 907 644 835

ABN GMHC 87 652 472 253

51 Commercial Road,

South Yarra VIC 3141.

Ph: (03) 9863-0444

Fax: (03) 9820-3166

Centrelink Income Statement

I ____________________________ authorise:

The VAC’s David Williams Fund to use Centrelink Confirmation eServices to perform a Centrelink enquiry of my Centrelink Customer details and concession card status in order to enable the business to determine if I qualify for a concession, rebate or service.

The Australian Government Services Australia (the agency) to provide the results of that enquiry to VAC’s David Williams Fund

I understand that:

The agency will use information I have provided to the VAC’s David Williams Fund to confirm my eligibility for relevant services and will disclose to the VAC’s David Williams Fund my personal information including my name, address, concession card status, payment type, payment status, income, assets, one-off payment, deduction and shared care arrangements.

This consent, once signed, remains valid while I am a customer of VAC’s David Williams Fund unless I withdraw it by contacting the VAC’s David Williams Fund or the agency.

I can obtain proof of my circumstances/details from the agency and provide it to VAC’s David Williams Fund so that my eligibility for relevant services can be determined.

If I withdraw my consent or do not alternatively provide proof of my circumstances/details, I may not be eligible for the services provided by VAC’s David Williams Fund

Name: ______________________________________ Centrelink No: ________________________

Signed: ____________________________________ Date ….... / ….... / 2024

Thank you for your assistance,

David Williams Fund

Office Use Only:

Updated By: _______________________________ Date: __________________________________

THH takes your privacy seriously. THH has a legal and ethical obligation to ensure the privacy of information relating to individual clients and their families.

THH’s Privacy and Confidentiality Policy reflects the principles outlined in the Health Records Act 2001, the Privacy Act 1988 (Commonwealth - incorporating the Privacy Amendment (Enhancing Privacy Protection) Act 2012) and the Privacy & Data Protection Act 2014 (Victoria) regarding the collection, use, disclosure, access and protection of any personal or health information we hold.

In line with these principles, THH Policy requires the organisation:

To only collect and use personal information with the client’s prior knowledge and consent

To only use the personal information provided for the purpose for which it was collected. This may include health service provision, research and auditing purposes.

To remove personal information from records when it is no longer required, unless it is legally required to be retained and archived

To ensure policies and procedures are in place to protect the personal information we hold

To ensure THH’s Privacy & Confidentiality Policy is available for clients and the public to access

Not to disclose personal information to other services or individuals without consent

Not to disclose personal information to other institutions and authorities unless required by law or other regulations or statutes.

THH also collects data about the use of our website and social media pages. This data is only used to track the performance of our website and social media pages. It is not used to identify individual users or collect personal information.

Feedback provided on THH’s website or social media pages about VAC services and programs is downloaded, de-identified and used by THH for service and program improvement.

Email/Social Media addresses provided via the THH website or Social Media will only be used to respond to specific user queries and will not be added to any mailing lists or disclosed to other parties without user’s knowledge and consent.

Clients and individuals have the right to access their personal or health information held by THH. Such requests are to be in writing using the THH Request to Access Client Care Records form, and addressed to the relevant service manager.

Further information is available from THH Privacy & Confidentiality Policy and THH’s Client Confidentiality Procedure.

For further information about THH’s Privacy and Confidentiality Policy, please contact VAC via https://thorneharbour.org/contact/, or call THH’s Privacy Officer on Tel: +61 3 9865 6700 or Toll Free: 1800 134 840.

If you feel the privacy of your health information or personal details has been compromised in any way at THH, please contact our Privacy Officer (contact details as above) about how to make a complaint.

Complaints about privacy and confidentiality breaches can also be directed to:

Health Services Commissioner, Complaints and Information

Tel: 1300 582 113 Fax: +61 3 9032 3111, or write to:

Health Services Commissioner, 26th Floor, 570 Bourke Street, Melbourne Vic 3000

Australian Privacy Commissioner	www.oaic.gov.au / enquiries@oaic.gov.au

Commissioner for Privacy & Data Protection

Tel: +61 3 8619 8719 Local Call 1300 666 444 Fax: +61 3 8619 8700 Local Fax: 1300 666 445

enquiries@privacy.vic.gov.au