Contract Application Form

£1000 and over

Introduction

Community Funding Programme has a total of £90,000 available. We are looking to contract with a number of organisations for various amounts of funding. For instance you could apply for between £5,000 - £45,000 dependent on how many people you work with, number of key geographical areas and priority groups.
In order to apply for funding you need to have a proven track record of delivering services and activities in the following work streams.
Weight Management
Increasing Physical Activity
Smoking Cessation
Alcohol Management.
Deadline for application submission: 19thFebuary 2018 at 16:30
Please ensure that you have read and understood the application terms and criteria beforecompleting the following application. This will help to clarify your proposal.

Your information

In the below section please include your organisation information. Unless you are a company or individual please leave the section about charitable aims blank. If you are not working with any partners please also leave this section blank.

Organisation Name
Organisation Address
Organisation Website
Social Media Links / Facebook:
Twitter
Other:
E-Mail Address
Details of Contact
Main Contact Name
Main Contact Address
Main Contact Telephone
Position in Organisation
Secondary Contact
Secondary Contact Name
Secondary Contact Address
Secondary Contact Telephone
Position in Organisation
Legal Structure / Which of the following best describes your legal Status
Charitable Incorporated Organisation / Charity Registered in England and Wales
Social Enterprise / Industrial and Provident Society / Constituted Community Organisation
Company Limited by Guarantee / Community Interest Company Limited by Guarantee
A Public Sector Organisation (GP Practice) / A Non-Government Organisation
Other / Please Specify:
Please state your relevant registration number:
Charity Commission Number:
Office of the Scottish Charity Regulator Number:
Registered Company Number:
State the day, month and year that your organization was founded. / DD/MM/YYYY
Tell us what your organisation or group does. (No more than 100 words)
Tell us briefly how you are set up e.g. the number of paid staff, volunteers, management committee members / trustees / directors.
Tell us what you currently offer, where, how and who are the beneficiaries?

Project Information

Tell usmore about your project

Project & People
Project Title
Area of Focus / Weight Management / Physical Activity
Stopping Smoking / Alcohol Reduction
Is this a new or existing project? / No more than 50 words
Please outline your proposed project.
How will the proposed service/activities meet the key performance indicators outlined in the guidance?
We are looking for projects to start from 1st April 2018. Do you see any problems mobilizing within this time frame?
What outcomes do you expect to achieve from the activities and services you will be delivering with this funding?
What systems and processes do you have to monitor, evaluate and report on this work?
How many people will the funding benefit? Please indicate in numbers below.
Total number of people:
Please indicate the number of people who will be working towards each change.
For example, if you are working 100 people on physical activity and stopping smoking you would put 100 in each of the boxes below.
Weight Management / Physical Activity
Stopping Smoking / Alcohol Reduction
Could you tell us what group of people you will work with or target?
Are these internal clients/service users or external? / Internal / External
If you are targeting external people, how will you plan to market your project to encourage engagement.
Duration and Location
How long will your project last for?
When do you expect the project to start and finish?
Start: / Finish:
How many groups/sessions or activities do you plan to run during the time you will receive funding from us?
Please tell us about the specific geographical area/s your project will work within.
Please provide description of community that will participate in your project such as age group, work, and other important information.
Tell us how often you anticipate this will happen each week or each month, the duration of each session and what time of day it will take place.
Experience & Support
What relevant experience do you have of delivering the projects you described and what was the outcomes for those you’ve previously delivered a service to?
If you have not run a service like this before, what training and support do you think you’ll need – please see guidance notes for support from Southampton Healthy Living.
Tell us about any challenges you may have delivering this project and how you will overcome them, including continuation or legacy of the project.
Impact
Why is your project needed? [ max 200 words]
What evidence do you have to show that your project is needed? How have you consulted with the people who will benefit from your project and what did you learn?[Max 200 words]

Funding

Tell us more about the funding you’re looking for

How much money do you require? / £
Tell us how you will use the money (No more than 200 words)
How is this made up? (please outline costs below)
List all of the individual items or activities that make up your project.
Provide a breakdown for each item if necessary. For example, don’t just put furniture, list the different items:
5 tables,
30 chairs,
5 desks

Include everything you will need for the project, even if you are not asking us to fund it (Add in additional lines if needed)
Give the total cost of each item or activity in column A, and put how much you want from us in column B.
If you want us to fund all your project costs then the figures in column A and column B will be the same
You must not include any VAT that you can claim back from HM Revenue and Customs.
Please check that you have added up the totals correctly.

Item or Activity / A
Total Cost / B
Amount requested from SHL
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
£ / £
Totals / £ / £
For the costs above, if the total in column A is higher than the total in column B, where is the rest of the funding coming from? [Max 100 words]
How have you worked out your costs? [Max 100 words]
What is the main source of funding for your current project and for how long do you have funding for?
Are there any other sources of funding for this project?
Do you plan to apply for additional funding other than SHL Community Programme Funding?
If so, please tell us the financial status of that project (who funds the Project, how much and for how long)

Organisational Financial Information

Financial Information
Your account must be in the name of the organization that is applying for a contract and will carry out the project. We require at least two people to sign each cheque or authorize a withdrawal.
Does your bank or building society account meet our requirements? / Yes / No
Bank or Building Society name
Bank or Building Society address
Postcode
State the organization name used on statements or passbooks
Is this the same as on your governing document / Yes / No
Summary of your most recent accounts.
Please submit with your application a copy of your most recent accounts
Are the figures below:
Information from your latest accounts approved by your organization. / Yes / No
A projection because your organization has been running for less than 15 months. / Yes / No
The Charity Commission has published useful information on accounting and reporting at:
If you’re a registered charity we’ll expect you to follow this guidance but if you are not, you may still find it helpful.
All applicants must provide income and expenditure figures. Give a projection for the first full year if your organisation has been running for less than 12 months. Schools should include the whole school budget.
Account year ending: dd/mm/yyyy / £
Total income for the year (A) / £
Total expenditure for the year (B) / £
Surplus or deficit at the year end (A - B) / £
Total Savings or Reserves at the year end. / £
Have your accounts been independently audited / Yes / No

Other Information

Some additional information that we would request

Where/How did you hear about the funding programme?
Have you read the guidance notes? / Yes / No
Do you have the following policies / Yes / No
Safeguarding Vulnerable Adult
Public liability insurance
Other insurance
Health and safety
Risk assessment
Data protection
Equal opportunity/diversity

Confirmation

In signing this declaration we agreed that:

The information provided in this application is correct.
We have read, understand and accept the Terms & Conditions of Funding for SVS
We will complete and return a Project Completion Report (PCR) within 3 months after conducting the project

We have adequate and appropriate insurance cover for our activities.
Name
Position
Signed
Date