Stroke Support 2018/19 GRANT PROPOSAL FORM
Deadline for Applications: 1st June 2018

Grant Number (for office use only):

The form has been designed so you can provide the standard information we need to assess your proposal. Your answers should show that you have considered thoroughly every aspect of your proposal.
Please read this carefully before you begin your grant proposal
Before you fill in this form please make sure that both your organisation and your proposal can meet ALL the generalcriteria set out in the information notes. If your organisation or your proposal cannot meet all of the general criteria then it will not be possible for us to consider your application. Your proposal also needs to contribute directly to at least one of theoutcomes set out in the ‘Information forgrant recipients, Stroke Support Scheme’.
Each section has a maximum word count including any tables or charts, if responses exceeds this, only the part upto the word limit will be considered.
All applications will be made electronically and sent to
If you have any queries regarding your application please contact
1. Contact Details
Name of your proposal
Full name of your Organisation/Group
Contact Name
Address
Post Code
Telephone Number
Email address
2.Does your organisation/group have legal status?
Please tell us the legal status of you organisation or group. E.g. Company limited by guarantee, registered charity, community group, sole trader
Company and/or Charity Number (if applicable):
3. When was your organisation/group set up?
4. How many people are involved in running your organisation/group?
Board/ committee members/ trustees
Paid employees: full time
Paid employees: part time
Volunteers
5. Organisation/Group aims and objectives.
Briefly describe your organisation/group’s main aims, objectives and activities
200 words
6. Aims and objectives of your proposal
a) Provide details of your innovative Stroke Support proposal. What does your proposal aim to achieve and how?
REMEMBER: Be specific about how your proposal will benefit Stroke survivors and their families/carers across thewhole County. Refer back to the information notes.
1000 Words
7. Need for the proposal
How do you know that there is a need for this activity?
(For example, by community consultation, user feedback, other factors etc.)
200 words
8. Each successful proposal will need to commit to all the below.
Please tick each statement below to confirm your acceptance:
Your proposal must:
Target Stroke survivors whose independence is at risk and offer support to them
Support families/carers of Stroke survivors
Collect set data for all participants and submit at agreed timescales
Contribute additional funding or resources in find to increase the scope of Stroke Support
Promote and publicise Stroke support to the wider population, to ensure it reaches all those in need locally
Encourage and develop referral relationships with Locality Teams and GPs
Deliver Stroke awareness raising and promotion, reaching the wider
general population in the locality area including anti stigma work
Offer support and appropriate signposting around benefits advice and other support to Stroke survivors
Offer quick, easy, open access systems including self-referrals
Utilise and develop asset based approaches and peer led support / activities
Meet identified local gaps / need via support activities
9. Implementation
a) Please explain your implementation plan including timescales for your proposal, using the table below where applicable:
Proposed delivery shouldbegin as soon as possible after award of funding and 1st July 2018.
150 words
b) Please describe your organisational experience to deliver this proposal.
150 words

When will your proposed activity begin?

10. Proposal Funding
Amount requested from this Stroke Support Scheme project grant
11. Breakdown of proposal costs
What will you spend this project funding on? Please provide a full breakdown of your total costs, showing how any grant awarded will be spent over the project period, using the table below.
Costs
Building / £
Equipment / £
Salaries (inc NI) / £
Patient transport / £
Volunteer expenses / £
Venue hire / £
Office (IT, phone, etc) / £
Leaflets, stationery and promotional materials / £
Training / £
Travel / £
Tutors and course fees / £
Management Charge / £
TOTAL / £
Applicant’s Funding
Contribution / £
Grant Applied for from CCC / £
12. Scheme Requirements
Please show whether you apply the followingpolicy requirements now or confirm that you will applyprior to funding award. If your proposal is to work with children or vulnerable adults, ALL staff and volunteers MUST have Enhanced DBS clearance and you MUST work to the CumbriaMulti-agency safeguarding adults guidelines. (We will ask successful applicants to providethe documents below prior to the release of funding)
Health and Safety Policy Apply now: Will Implement:
Safeguarding Adults policy Apply now: Will Implement:
DBS in place Have now: Will Implement:
Equality & Diversity policy Apply now: Will Implement:
Complaints procedure Apply now: Will Implement:
RequiredInsurance cover Have now: Will Implement:
Are any premises you propose to use accessible to people with disabilities and those using public transport?
YES NO
13. Declaration of interest

The staff of Cumbria County Council must declare any relationships or interests with individuals or organisations who apply for grants.

Do you know about any personal relation or

link to acouncillor or of anyone employed Yes Noby Cumbria CountyCouncil?

Name:

Nature of relationship:

The information on this form will be processed by or for Cumbria County Council. We may hold the information you give us on computer, it will be used to assess the grant application. We may provide copies of the information to individuals or organisations that are helping us assess applications or monitor grants.

I confirm that to the best of my knowledge and belief, all of the information I have given in this proposal form is true and correct, and I will ensure that I inform you immediately of any changes to the information provided.

I also confirm that the proposal in the application falls within the objects and powers of the constitution or Memorandum and Articles of Association (where applicable)

Name: / Name:
Position: / Position:
Signed: / Signed:
Date: / Date:

(TWO signatories are required)

By signing and submitting this form, I declare that the applicant organisation/groupcan meet all the general criteria set out in the guidance notes. I also understand that should this application be successful, the information contained in this form will be used as the basis of the funding agreement.

Your completed proposal will be e-mailed to

Checklist for applicants

As a final checklist please refer below:

 I have read and understand the informationnotes

 I confirm that this proposal meets the outcomes for the scheme

 I confirm that this proposal meets all general criteria for the scheme

 I have answered all of the questions on the form

 I have told you my proposal will benefit the whole county and how

 I have told you how much money I am requesting from the fund

 I can provide the following documents:

  • Equality & Diversity Policy
  • Health and Safety Policy
  • Complaints Procedure
  • Proof of full Disclosure and Barring Service disclosures for ALL staff and volunteers working with children or vulnerable adults
  • A copy of the constitution, set of rules or articles of association (where applicable)
  • Safeguarding adults guidelines and policy
  • Insurance certificates that indemnifyCumbria County Council against public liability and professional negligence

In addition, please make sure that:

 You have kept a clear copy of the form for your own records

 You have clearly marked any additional sheets and each supporting document with the relevant question number and the name of your organisation/group.

1