Short Breaks Award 2017-2018

Community Access Grant Application (maximum of £500)

with other children, if you are a parent/carer

Our Priority for this year is Healthy Sleep is this the same for the CAG?

Contact information

  1. Contact details of organisation/applicant (please complete as appropriate)

Organisation/Applicant
Position
Address
Postcode
Email address
Website (for organisations)
  1. The main contact person for this application

Name
Position in organisation
Contact address
Postcode
Telephone number
Email address

Organisation Information

  1. How would you describe the organisation (if applicable)?

Please tick boxes that apply to the organisation or applicant

Registered charityCharity Number ………………………………..

Voluntary or CommunitySelf help group/forum

Social Enterprise

Childcare provider Ofsted Registration No. if applicable

Company Limited by

Guarantee`

Individual or Parent/carer

Project/Service/Activity/ Information

  1. What is the title of your project/service/activity?
  1. Please give details of your project/service/activity with a breakdown of what this funding will pay for if your application is succesful (e.g. a helper for 3 hours a week for 10 weeks to help support 2 children with autism. (Maximum 200 words)
  1. Please describe the intended benefits of the service that the grant will support
  1. How many children will benefit from the grant?
  1. How many sessions will the grant cover if you are successful?
  1. Please tell us how much money your are requesting?

£
  1. How will you involve users/participants in the development of your project/service/activity? How will you seek their feedback?

(Maximum 100 words)

  1. Have you applied to Southend Borough council for any grants for this project or any other grant in the last 3 years?

Yes No

If yes, please give details below:

Dates:
Details of award:
Amount:
  1. Documentation

Please tick to confirm whether you have the following documentation and state the amount of cover:

Public Liability InsuranceAmount of cover......

Employers Liability InsuranceAmount of cover ......

Indemnity InsuranceAmount of cover......

Adult Safeguarding Policy

Recruitment Policy

Children Safeguarding Policy

Staff Training Policy

Health and Safety Policy

Equality and Diversity Policy

Privacy Policy
The information you have supplied in this form will be used to process your grant application. In order to make a decision on your application, some of the
de-personalised information provided may go into a public decision report. In addition, your application form may be shared with third parties and partner agencies who will be involved in the decision making process or who can verify specific facts within your application.
In addition, we may be required to disclose information outside Southend-on-Sea Borough Council to help prevent fraud, or if required by law.
We may not be able to process your application if you do not provide all the requested information.
Under Central Government’s Open Data agenda, if your application is successful, details of grants of £500 and over can be published on Southend-on-Sea Council’s website. No personal information will be published.
Declaration
I am authorised to apply for the grant set out in this application.
I confirm the following:
  • All the particulars and information given in the application form are correct
  • I will inform Southend-on-Sea Borough Council if any of the particulars and information given cease to be correct
  • I have read and understand the Application Guidance and agree to provide a report detailing the outcomes of any grant funding
  • I understand that the grant applied for is for this year only, with no expectation of funding in future years.
I agree to the Declaration and Privacy Policy above
Name ...... Signature ......
Position ...... Date ......
Second signature from a member of the organisation
Name ...... Signature ......
Position ...... Date ......

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