Time to Change: Blackpool

Champions Fund 2018 Application Form

Please make sure you have read the Blackpool Champions Fund 2018 Guidance and had a look at the Social Contact Event Toolkit before completing your application. If you need any support in completing the application please do not hesitate to contact

Your Contact Details

Contact name / Group (if relevant)
Email address / Phone Number

About Your Activity

What is the name of your activity?
When will your activity take place?
Please list all dates.
Where will your activity take place?
Please list all activities.
Tell us about your activity or event/s (max 100 words)
How many people will your activity reach?

Social Contact

How will you promote and run your activity to make sure people with and without mental health problem come together and have a meaningful conversation? (max 100 words)
How many social contacts do you think will happen because of your activity?
How many Time to Change champions will be involved in your activity? / Already registered Champions:
New Champions:
How will people sharing their personal experience of mental health problems be supported? (max 50 words)
How will you deliver your activity safely considering about safeguarding and health and safety? We recommend no activity is delivered individually or to unsupervised children and young people. (max 50 words)

Impact

How will you promote your activity? (max 50 word)
How will your record your activity to show the difference it has made? (max 50 words)
Please tick to confirm you understand and agree to the requirement to complete and submit the grant report template for your activity by the 9th March 2018

Budget:Use the table below to tell us how much your activity is going to cost

Item / Description / Amount
Total requested

Completing and submitting your application

Please email your application form to 5pm on the 11th December 2017 (Winter Grant) and 5pm on 11th March 2018 (Spring Grant). You will receive a reply confirming receipt of your application form. Notifications of awards will be communicated by the 5th January 2018 and 5th April 2018.
Application check list / Tick
Have you explained how your activity will ensure social contact between people with and without a mental health problem?
Have you explained how your activity impact will be recorded?
Have you checked your budget for accuracy?
I have registered to be a Time to Change Champion (18 and over only)

Declaration

I confirm that I am duly authorised to sign this declaration. I certify that the information given in this application is true.I understand that any offer of a grant will be subject to terms and conditions. I confirm that the lead organisation/champion has the power to accept this grant if the application is successful and to repay it if the grant conditions are not met.
I confirm that if successful the activity will be delivered:
  • in accordance with appropriate insurance requirements
  • in line with best practice with regards to safeguarding and health and safety
  • in a fair and open manner without distinction as to race, religion, age, gender or disability, and incompliance with relevant legislation.
I understand that if we make any seriously misleading statements (whether deliberate or accidental) at any stage during the application process, or if I knowingly withhold any information, this could make our application invalid and we will be liable to repay any funds.
I understand that all funded projects must undergo monitoring and evaluation and we confirm that we will co-operate with this and any related activities that are required of us by Lancashire Mind. If successful, we will contribute to meetings within our area, support our activity beneficiaries to share their stories, share learning from our project and any experience we have of working with appropriate commissioners.
I further confirm that Lancashire Mind may use any part of the application for evaluation, research or publicity purposes.
I have not altered or deleted the original wording and structure of this application form as it was originally provided or added to it in any way.
By adding my name to box below I confirm that the lead organisation is responsible for the administration and finances of the activity.
First name
Last name
Group (if relevant)
Position in organisation (if relevant)

Data protection

Lancashire Mind will store the information you provide on a database and spreadsheets. Your information will be used during assessment and the life of your grant (if awarded) to administer and analyse grants, and for our own research purposes. Your details will be circulated and discussed in confidence with any person or organisation helping to assess and monitor this application. These organisations may include accountants, external evaluators, and other organisations or groups involved in delivering the project.