On-Line Nursing Bursary Application

Nursing Student Bursary Application Form

200 Terrace Hill Street, Brantford, Ontario N3R 1G9, Telephone 519-751-5544, Facsimile 519-751-5575

Personal Information:

Applicant Name:
Address:
Home Phone:
Home Fax:
Hometown
Secondary School
E-mail:

Current Status (Select One): Year 1 Year 2 Year 3 Year 4

Graduation Date:

Clinical Interests: (Please list your top three areas of clinical interest)

Please note: A cover letter must accompany your application. It can be emailed to lzaitchik@bchsys.org or sent by standard mail Attention: Brittany Timothy to the address listed at the top.

Leisure Interests/Hobbies:

ANNUAL HOUSEHOLD INCOME
A. Expected Personal Earnings
B. Expected Earnings of Spouse
C. Expected Parental Assistance
D. Cash on hand
E. Scholarships / Other Bursaries
F. Expected Student Loans
G. Other Income - Please specify



Total Annual Income:

ANNUAL HOUSEHOLD EXPENSES
a. Tuition
b. Books & Subscriptions
c. Rent/Mortgage
d. Utilities
e. Telephone-Internet
f. Food
g. Clothes/Laundry & Cleaning
h. Insurance (Life/Medical/Dental)
i. Transportation Expenses
j. Recreation
k. Personal Expenses
l. Other (please specify)


Total Estimated Annual Expenses

BUDGET SUMMARY
Total Income (A)
Total Expenses (B)
Estimated Deficit (A-B=C)

Total Accumulated Student Loans/Outstanding Credit Balance to date

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