APPLICATION FOR FUNDING FOR 2015/16
Arun Wellbeing & Health Partnership
Small Grants Fund June 2015– grants up to £1000
To apply to the Arun Wellbeing and Health Partnership (AWHP) Small Grants Fund 2015/16 please complete a copy of this form electronically (preferred) and email to . If electronic completion is not possible please send a hard copy to Claire Dower, Wellbeing Information Officer, Arun District Council, Arun Civic Centre, Maltravers Road, Littlehampton, BN17 5LF, and allow plenty of time for the document to reach us before the deadline.
Deadline for receipt of applications: Friday 17 July 2015

1.  Brief name/description of the project/activity for which you are applying for funding (max 6 words)

1a What is the amount applied for from this fund (maximum £1000)? / £
1b Is this part funding or whole funding? / PART AMOUNT / WHOLE AMOUNT

2. Name and contact details of the person completing this form (Please include postal address, telephone, email and website address)

3. Your organisation. Are you (please complete one line)

Tick as appropriate / Registered number
Registered Charity
Other (please specify)

4. Briefly explain the purpose and activities of your organisation

The following questions relate to the specific Project or Activity for which you are applying for funding

5. Which of the AWHP priorities does it fulfil (tick all that apply). See the guidance notes for detailed explanation

Prevention, Support and Information
Improving Mental Wellbeing
Tackling Health Inequalities Across the District
Older People
Young People & Children
Patient Care
6. In which ward or wards will it take place? Please note that activities or projects in the following wards/areas will be given priority: Ham, Wick with Toddington, Beach, River, Allengate Estate (Rustington), Marine, Hotham, Pevensey, Trees Estate (Bersted), Orchard

7. Describe the proposed project or activity (Maximum 100 words)

8. What outcomes are you aiming for?
9. How will you measure the success of the activity or project?

10. What consultation has taken place with the people who will be the beneficiaries of this project/activity? What evidence do you have that the activity is needed?

11. How many individuals will benefit from the project

12. Risk (Please describe any potential obstacles to the implementation of the project)

13. How will you sustain this project or activity after the grant is used? Do you have an ‘exit strategy’?

The following questions relate to the funding and resources for the Project or Activity
14. How do you plan to fund this project or activity? / £
Funding applied for from AWHP (maximum £1000)
Funding applied for from other organisations (confirmed) – please list each organisation and amount*
Funding applied for from other organisations (not yet confirmed) – please list each organisation and amount*
Funding supplied by your organisation
Total Project Cost

* (Please note that you are legally obliged to inform us if during the course of the application process you are granted the funding from another source for the same project or part-project for which you are applying to AWHP small grants. Also if your project is dependent upon funding from other sources any AWHP decision to award a grant might be deferred until that other funding is secured.)

15. Please provide a breakdown of costs for how the grant money will be spent:

Item: / Cost:
TOTAL:
16. What in-kind support (if any) is there for this project?
From other organisations (confirmed) – please describe
From other organisations (not yet confirmed) – please describe
Provided by your organisation – please describe

17. When would the activity/project for which you are applying for funding take place or start? (Please note as stated in the guidance notes that funding will not be provided for activities due to take place prior to the end of September 2015)

18. Please provide bank details including name of account, sort code and account number as any payment, if awarded, will be paid by BACS transfer.

19. CHECKLIST: Please tick to confirm whether you would be able to supply evidence of the following items if requested. Please do not send copies with the application form unless requested.

Item / Yes / No / Not applicable (please state why)
Safeguarding Children Policy
Safeguarding Vulnerable Adults Policy
Confirm that staff and volunteers have relevant and up to date Disclosure & Barring Service checks, if working with children or vulnerable adults
Health and Safety Policy
A risk assessment for the activity/project being applied for
Equal Opportunities Policy
Compliance with the Disability Discrimination Act
Public Liability Insurance cover/*
Employers’ Liability Insurance Cover
Signed and dated constitution or set of rules

If you need any assistance or information with regards to constitution or policies you can request advice from Voluntary Action Arun and Chichester telephone 01243 840305, email , website www.vaac.org.uk

20. DECLARATION: I confirm that to the best of my knowledge, I have answered all the questions fully and accurately, and declare that should a grant be awarded, the money will be used only as described in the application form and in accordance with the grant terms and conditions.

Signature
(scanned signature acceptable if
submitted electronically)
Print name
Date

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