East Lancs Clinical Commissioning Group

Prescription for Wellbeing Grants

2017/18

Application Form

Please read guidance notes

Applicant - Organisation
Project Name
CVS Use Only / APPLICATION NO: / Date Received
Amount Req (£)
Date Result Acknowledged
Unsuccessful / Deferred / Successful
Burnley / Pendle / Rossendale
B1 / B2 / B3 / P1 / P2 / P3 / R1 / R2 / R3

East Lancs Clinical Commissioning Group

Prescription for Wellbeing

APPLICATION FORM

Please refer to the Prescription for Wellbeing Guidelines to help you to complete this form.

SECTION ONE – GROUP & PROJECT DETAILS

Name of Group
Name of Project/Activity
Where is your group based? (address)
When was your group established?
How many people are involved in the group? / Committee / Volunteers
Paid Staff / Members
Is your group part of a larger organisation? If yes, please provide brief details.
Your group must have a set of rules or a constitution - please supply a signed copy.
(If you don’t have the above, please contact CVS for support & guidance)
Your group must have procedures to cover equal opportunities andchild and vulnerable adult safeguarding?
Please enclose a signed copy
(If you don’t have the above, please contact CVS for support & guidance)
Has your group received any other grant from East Lancs CCG? / Name - project/activity
Application date
Amount received
Signature / Name in Block Capitals / Position in Group

SECTION TWO – CONTACT DETAILS

(Section Two is confidential and will be used for administrative purposes only)

Contact Name
Details of the person who is able to discuss this application.
Contacts position within the group
Address of contact (if different from group address)
Postcode
Contact Numbers / Home
Work
Mobile
Email Address
Group Bank/Building Society Name
Address
Postcode
Cheques payable to:

SECTION THREE – PROJECT DETAILS

1)Name of project/activity.

2)What does the project or activity involve?

3)Who & how many individualswill benefit from the project/activity?

4)Are there any particular problems/issues associated with the area in which the project/activity will take place?

5)How has need for the project/activity been identified?

6)Where and when will the project/activity take place?

7)What resources and support does the project/activity need? Are you working with partner organisations?

8)How does the project contribute to theCCG strategic aims of the Prescription for Wellbeing Programme Outcomes? (see guidelines)

9)What will be the Outcome/s of your work, especially in relation to the ABCD criteria (see guidance notes)?

10)How will you measure the project’s success against the intended outcomes (as in the guidelines)?

11)How will you monitor costs and your ability to deliver? Has additional funding been identified if required?

12)Additional Information

13) Which district will the project be delivered in?

Burnley

Pendle

Rossendale

SECTION FOUR – FINANCIAL DETAILS

Please provide a detailed breakdown of how East Lancs CCG Grant will be spent and enclose any evidence of money needed, e.g. estimates, quotations
ITEM / COST
How much money do you require in total to provide your project/activity? / £ / P
How much money are you requesting from East Lancs CCG Grants? (Max £5,000 )
How much income did your group receive in the last 12 months?
Details of other funding received.
Please ensure you provide a copy of your latest accounts
Do you have a Bank Account with at least 2 unrelated signatories? Y / N

SECTION FIVE – DATA PROTECTION

The 1998 Data Protection Act requires that we have permission to store your details on a confidential database. Your personal details will not be shared with any other outside organisations. However, for the purposes of grant monitoring we will need to pass on details of your group including budget breakdown relating to your grant. If you are successful your group name and project details will be used for publicity. We may also send you information about other funding opportunities and community development information. I give consent for our group details to be stored on a confidential database and used for publicity purposes.
Signature
Date:

SECTION SIX – EQUAL OPPORTUNITIES MONITORING FORM

Name of Organisation
Location of Activities
The above named organisation is set up to develop and promote voluntary/community/faith sector activities. We recognise that, in our society, both groups and individuals have been, and continue to be, discriminated against. Therefore, we aim to secure genuine equality of opportunity in ALL aspects of its activities. The following statement aims to ensure that no group or individual receives less favourable treatment, or is disadvantaged by conditions or requirements that cannot be shown to be justifiable.
The above named organisation, opposes discrimination on the grounds of age, race, gender, status, sexual orientation, religion, disability, marital status, income or circumstances, language, HIV or other health related issues, and ALL forms of direct or indirect discrimination that restricts or hinders the promotion of equal opportunities. The organisation is committed to achieving equal opportunities in all aspects of its existence, by compliance with, and in the spirit and ethos of equal opportunities legislation.
Signature
Date

EAST LANCS CCG GRANTS

DECLARATION Please ensure two non-related people authorised to sign on behalf of your group sign the application form.
I confirm that the information contained in this form is accurate.
Name in block capitals
Signature
Position in group
Date

APPLICATION CHECKLIST

Have you included the following with your application? / Yes / No
A fully completed application form
Your group’s rules or constitution
Your group’s annual accounts/financial breakdown/forecast
A copy of your group’s Safeguarding policy
All other relevant documents

Please return your completed application form to: -

East Lancs CCG Grants.

BPRCVS

The CVS Centre

62/64 Yorkshire Street

Burnley

BB11 3BT

Tel:01282 433740 ext 1007

E-Mail:

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