Please read the Guidance Notes carefully before completing this form.

Please return this form as soon as possible, and no later than 16th April 2012to:

Lewisham Arts Service, 2nd Floor Laurence House, 1 Catford Road, London,SE6 4RU.Tel: 020 8314 7730.

Take Part Extra Fund amount applied for:

Would you accept a reduced grant?YesNo

YOUR ORGANISATION

1. / Name of organisation
2. / Address including full postcode
3. / Name of contact person(s)
4. / Position in organisation
5. / Telephone number(s)
6. / Email and website
7. / What is the organisation’s legal status? / Registered Charity  Number:
Company Limited by Guarantee  Number:
Other - please specify:
10. /
What governing documents and policies do you have in place? You may be asked to provide copies of these documents.
 Governing documents for your organisation e.g. constitution  Public liability insurance
 Equal opportunities policy  Volunteering Policy
 Child protection and vulnerable adults policy  Health and safety policy
If you are working with children or vulnerable adults, Lewisham Council require that you have appropriate safeguarding systems in place. Please tick the relevant box:
 I confirm that staff/volunteers working on the project require and have had appropriate CRB disclosure.
OR
 I confirm that staff/volunteers are not required to have CRB disclosure for this project.

YOUR ACTIVITY

11. / Name of the activity:
12. / Type of activity e.g. music, visual arts, multi arts, drama, literary, dance:
13. / When will the activity take place: / Start Date / End Date
14.
/
Please describe your proposed project.Explain how it supports the values of the Cultural Olympiad.
15. / Location(s) of activity including postcode(s):
16. / Please give details of marketing activities you will undertake to promote the activity.
How will you will involve as wide a range of people as possible in the activity ?
17. /
Please describe how your project meets key priorities of the Fund.
You may continue on one A4 sheet if you wish.
18. /
Please describe how you have established a need for the activity and any consultation you have undertaken:
19. /
Please outline your track record in delivering successful arts projects:
20. / Number ofevents that the activity will include and the estimated attendances(Seesection 8 of the guidance notes ‘Events and attendances’): / No. of events / Attendances
21. / How many people do you estimate will benefit from the activity: / Audience / Participants
22. / What percentage of these do you estimate will be Lewisham residents: / Audience / Participants
23. /
Please detail your anticipated outputs and outcomes.
Outputs are the specific steps you will take to achieve your objective. Outcomes are the impact or change you hope to achieve as a result of the service you provide. Please see section 5 of the Guidance Notes for details of what we want the fund to deliver.
Outcomes / Outputs
24. /
Please use this space to tell us anything else that you would like us to consider when assessing your application. See the assessment criteria in section 7 of the Guidance Notes.

YOUR FINANCES

24. / Banking arrangements: payments will be made directly into the organisation’s bank account. Please give details of the account into which the grant should be paid.
Name and address of Bank or Building Society
Account Name / Account Number / Sort Code
Has your organisation received previous payments into this account from Lewisham? / Yes  No 
25. / Please give a breakdown of the income and expenditure for your proposedactivity. You must demonstrate at least 30% match funding of which 15% can be ‘in kind’ contributions(see section 6 of the guidance notes ‘Match funding’). Your total income and total expenditure must be the same:
INCOME
Earned income (ticket sales, fees etc.)
£
£
£
£
£
Subtotal
/ £
Public funding (egBig Lottery, Arts Council):
Applied for / Approved
£
£
£
£
£
Subtotal
/ £
Private income (eg donor, sponsorship):
Applied for / Approved
£
£
£
£
£
Subtotal
/ £
Support in kind (eg time, services etc.)
£
£
£
£
Subtotal
/ £
Arts Festival Fund amount applied for:
/ £
TOTAL INCOME
/ £
EXPENDITURE
Artistic fees and staffing costs
£
£
£
£
Subtotal
/ £
Other artistic costs (eg venue hire, production, materials)
£
£
£
Subtotal
/ £
Overheads (e.g. phone, rent, heating)
£
£
£
Subtotal
/ £
Marketing and documentation (eg design and print, photography)
£
£
£
Subtotal
/ £
Value of support in kind
£
£
£
Subtotal
/ £
Other expenditure
£
£
£
Subtotal
/ £
TOTAL EXPENDITURE / £
DECLARATION