Community Inclusion and Participation Grants 2016 Application Form

The Disability Services Commission in partnership with VisAbilityLtd.

Please read the Community Inclusion and Participation Grants funding guidelines and discuss your proposal with the VisAbility Grants Officer on (08) 9311 8202 before completing the application form.

Submitting your application

Applications must be received by VisAbility Ltd by Friday 21st October 2016.

Late applications will not be accepted.

Please submit your application via one of the following options:

Email:

Post:

Community Inclusion and Participation Grants

VisAbility

PO Box 101

VICTORIA PARK WA 6979

Hand delivered:

Community Inclusion and Participation Grants

VisAbility

61 Kitchener Ave

VICTORIA PARK WA 6100

Applicant organisation details

Full name of your organisation:

Address:

Suburb:

Postcode:

Postal address (if different to above)

Full name:

Address:

Suburb:

Postcode:

Contact person details (program or project contact)

Title (for example Mr, Mrs, Dr):

Full name:

Position:

Phone:

Email:

Organisation contact (CEO, Chair, President)

Title (for example Mr, Mrs, Dr):

Full name:

Position:

Phone:

Email:

Is your organisation incorporated?

YesNo

Please let us know if any people involved with the development and delivery of your project or program identify with one of the following? (Please tick)

DisabilityAboriginal or Torres Strait IslanderCALD

Have you discussed your application with the Grants Officer at VisAbility Ltd?

Yes No

Auspicing organisation details (complete this section if applicable.)

Name of the auspicing organisation:

Contact person (full name):

Position:

Address:

Suburb:

Postcode:

Phone number:

Email:

Postal address (if different to above)

Is the organisation incorporated?

Yes No

Grant management details

Does the applicant organisation (or its auspice) have an Australian Business Number (ABN)?

Yes No

Is the applicant organisation (or its auspice) registered for GST? (This is a requirement).

Yes No

Does the applicant organisation (or its auspice) have an annual financial report for the previous financial year?

YesNo

Does the applicant organisation (or its auspice) have a bank account in its name with a minimum of two signatories?

 YesNo

Does the applicant organisation (or its auspice) have public liability insurance?

Yes No

Does the applicant organisation (or its auspice) receive Disability Services Commission funding?

YesNo

Bank account for grant payment (Please complete the following details.)

Account name:

BSB number:

Account number:

Bank name:

Insurance details:

Grant criteria

Program or project title:

Criterion 1: Describe how your proposed initiative will improve the inclusion and participation of people in your community. (Weighting 50%)

For example:

  • demonstratehow it will increase or improve the inclusion and participation of people with disability in the community
  • demonstrate how inclusion and participation will be sustained once the program is completed
  • demonstrate how it raises awareness related to inclusion and participation for people with disability in the community
  • demonstrate how you engaged with people with disability to develop your initiative
  • support any or all of the Count Me In strategy elements of:
  • Participation and contribution in all aspects of life
  • Welcoming communities
  • Lifelong learning in inclusive settings
  • Enabling information and technologies
  • Economic and Community Foundations
  • Well planned and accessible communities.

Answer here in fewer than 500 words

Criterion 2: Is there a clear and realistic outcome and delivery plan, evaluation framework and budget identified? (Weighting 35%)

Outcomes can include, but are not limited to:

  • an increase in the number of people with disability participating in the program or project
  • an increase in the skills of participants
  • an increase in the level of social interaction of participants
  • an increase in awareness by the community of the issues facing people with disability when concerned with inclusion and participation.

The success of your program or project could be measured by, but not limited to:

  • how this project is sustainable once the use of this funding is completed
  • how participants have been able to utilise the skills they acquire through the program in “real life” situations
  • feedback from participants with disability, families, carers and volunteers
  • long-term benefits or impacts for people participating, especially once this program is completed
  • long-term benefits or impacts for the community
  • requests for further development or continuation of your program or project at its completion.

Answer here in fewer than 500 words

Criterion 3: Demonstrate your organisation’s capacity to manage and administer the program or activity. (Weighting 15%)

  • Have you provided a detailed, itemised budget?
  • Have you provided a clear project management monitoring and reviewing process?
  • Have you conducted a risk assessment of your program or project?

Answer here in fewer than 500 words

Budget Details

What is the total cost of the program/project (GST exclusive)?

Please complete the form below giving as much detail as you can.

Budget for Grant Money Requested

What is the total amount of funding you are requesting (GST exclusive, maximum $50,000)

Please include all the individual items you wish to receive funding for and how much each item will cost

Expenditure item (eg paint brushes) / Total dollar amount for each item / At what stage will the money be spent? ie dates/month

Budget from other Funding Sources (ie the money your organisation is contributing)

What is the total amount of other funding you will receive (GST exclusive)?

Please include all the individual income sources and items that will be funded by another source/s and how much each will cost.

Income source (eg your organisation, Lotterywest funding) / Total income amount / Expenditure item / Amount for each item / At what stage will the money be spent? ie dates/month

What in-kind contribution (services you will receive instead of money eg in-house printing) will you receive?

In-kind contribution source (eg your organisation) / Individual item (eg office space) / Amount for each item (if applicable)

Applicant’s certification

This section must be completed by auspicing organisation, if applicable.

I certify that the information provided in this application is, to the best of my knowledge, true and correct and that I have the authority to submit this application. (Please complete the following fields).

Full name:

Position:

Organisation:

Date:

Signature:

Checklist

Essential attachments

Certificate of Incorporation (applicant organisation or its auspice where applicable).

Australian Tax Office GST registration (applicant organisation or its auspice where applicable).

'Statement by a supplier form', if no ABN number (applicant organisation or its auspice where applicable).

Income and budget sheet.

Additional supporting documents.

Annual financial report from previous financial year.

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