ACTIVITIES & CAMPS
SMALL GRANTS
APPLICATION FORM
2014 - 2015
Privacy Statement

Diabetes Queensland is collecting your information through this form for the purpose of assessing your application for Kids Camps and Activity funding. Your information may be disclosed to the Australian Government Department of Health and Aging for the purpose of NDSS reporting. Your information will not be disclosed to any other third parties without your prior consent.

For more information on how Diabetes Queensland deals with your information please read the Diabetes Queensland Privacy Policy available on our website:

Diabetes Queensland Grants Application Form

Grant application closing date: Friday 6th of February 2015
PLEASE complete this form electronically, then print, sign and submit by post (details below). Hand written applications will not be accepted.
Organisation

Please provide the following information about your organisation and your role.

The Application Form must be signed by the Department Manager.

Name of Organisation:

ACN/ABN:

Organisation’s Representative

Position/title:

Address:

StatePostcode

Phone number:( )

Mobile number (if available):

Email:

Activity* title:

Do you have a process in place to check Blue Cards for all staff/volunteers assisting with the camp?

Yes No If no, please indicate a reason why

Intended Start Date:

Anticipated End Date:

TOTAL Funding requested $

  1. Description
Describe the typeand length of the event/camp to be conducted. What type of activities do you plan to undertake with the participants?
  1. Objectives
What are the objectives of the activity/camp?
  1. Policies and Procedures
Does your organisation have in place appropriate policies and procedures to ensuresafety and quality standards are maintained during the camp/activity?
E.g. Camp providers should have in place a Camp Manual that includes policies and procedures for:
-Staff numbers (including appropriate health professionals)
-First aid
-Emergency health care
-Blood glucose monitoring
-Hypoglycaemia
-Hyperglycaemia
-Insulin administration and adjustment
-Nutrition and dietary management at camp
-Child protection
-Sharps disposal
-Emergency procedures, AND
-Any other relevant safety concerns
Activity providers should have in place a thorough risk management plan that addresses some or all of the items outlined above.
Please provide an overview of the policies or plan that you have in place to ensure safety and quality standards are maintained.
  1. Demographics
Describethetarget groupfor the camp/activity (e.g. children with diabetes aged 12-17 years, siblings and/or parents).
Please indicate the projected number of participants.
  1. Outcomes
What outcomes do you hope to have achieved at the end of the event/camp?
  1. Risks
Describe any potential or actual risks involved in the event/activity.
How do you plan to manage these risks?
  1. Conflict of Interest
Are there any conflicts of interest, or potential conflicts of interest, that you should report to Diabetes Queensland?
  1. Insurances
Please describe the relevant insurance policies that your organisation has in place – e.g. public risk insurance, professional indemnity insurance, comprehensive motor vehicle insurance, workers compensation insurance, etc. If your application is successful,you will need to demonstrate appropriate insurance cover.
  1. Evaluation
How will the event/camp be evaluated?
Note: Pending grant approval, a report detailing activities and outcomes is to be submitted to Diabetes Queensland upon completion of the activity/camp. Outcome reports must be received in a timely manner for funding to be awarded in future funding rounds.
  1. Diabetes Queensland acknowledgement
Please indicate how you intend to acknowledge Diabetes Queensland’s contribution in your communication materials and/or advertising mediums (online or other).
Note: It will be a requirement for successful applicants to include a supplied Diabetes Queensland logo on all marketing material and resources.
  1. Funding
Indicate the total amount of funding requested and a detailed breakdown of what it will be used for in the activity/camp. e.g. accommodation, resources, catering, mail outs, stationary etc.
Please declare any other funding sources that you have secured, or are seeking, to deliver this activity.
NOTE: Grants of up to $5000 are available; however, the amount awarded will be dependent upon the type of activity/camp and subject to approval of Diabetes Queensland.

Authorised Signature

Printed name

Date:

Return completed form to:

Health Services Delivery Manager,

Diabetes Queensland,

GPOBox 9824BRISBANE QLD 4001

DIABETES QUEENSLANDoffice use only

Fund Do not fund* Delay until next round*

*Indicate why

Date application received

Reviewers

Name / Position / Signature / Date

END of Document

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