South Ayrshire Health and Social Care Partnership

South Ayrshire Health and Social Care Partnership

Localities Health and Wellbeing Small Grants FundApplication Form

(Please see guidance notes for further information)

Section 1 - about your organisation

Name of organisation/group
Address
(including postcode)
Name of Main Contact
Main Contact E-Mail
Main Contact Phone
What type of organisation are you? / Voluntary Group / CIC
Registered Charity / SCIO
Non constituted
Other - Please state
Have you accessed funding for this activity from another source? If yes please name the funding source
If non constituted please name Sponsor Organisation (see guidance)
Which of the following best describes the areas in which your organisation is active?
Older People / Care & Support / Advice & Information
Adults / Disabilities / Other
Please provide a brief summary of the aims, objectives and activities of your organisation or group.

Section 2 - about your initiative/activity

Purpose of funding application (please refer to the funding criteria in the guidance notes)
Describe your initiative/activity in more detail -(Please indicate the main objectives, targets and timescales).
Please identify which particular groups your activity will target, e.g. older people, long term conditions, mental health etc. this information should include projected numbers of participants who will benefit from the activity that you are seeking funding for.
What is the need for this initiative/activity?
Please state how you will evaluate your initiative/activity (evidence could include photographs, questionnaires, impact statements or focus groups).
Is the initiative/activity you are seeking funding for part of a wider project, if so please describe.

Section 2 - about your initiative/activity (continued)

Which Health and Wellbeing Outcomes will your initiative/activity contribute to? (see guidance for further information). Please tick all that apply.
Healthier Living / Reduced Health Inequalities / Positive Experiences & Outcomes
Quality of Life
People are safe / Independent Living / Carers are supported
In which Locality will your initiative/activity take place? (please tick)
Ayr North and Villages / Ayr South and Coylton
Prestwick and Villages / Troon and Villages
Maybole and North Carrick Villages / Girvan and South Carrick Villages

Section 3 – Financial Information

Please provide (if appropriate):

A signed copy of your Constitution or Memorandum and Articles of Association (if constituted) / Yes/ No
A copy of your most recent Bank Statement (showing the account name, account number and sort code.) / Yes/ No
Name of Bank/Building Society
Account Name and Number
Sort Code
Total Cost of Project / £
Amount of Funding Requested / £
Please breakdown the cost of everything you require for this project
Item/ Details / Total Cost / Cost Requested
TOTAL COST

Declaration

On behalf of (name of organisation): ______

I hereby apply for consideration for funding as detailed above. I confirm that all information given is correct and that, if awarded funding, the organisation will comply with South Ayrshire Health and Social Care Partnership’s conditions of grant, including completion of a small Evaluation Report within six months of award, detailing outcomes and funding expenditure.

I understand that the information supplied on this form, specifically group’s name, reason for and amount of award, will be held electronically and used for administration purposes. It may also be published on the South Ayrshire Health and Social Care website or local press. I understand this to exclude bank/financial details.

Name (BLOCK CAPITALS): ______

Signed: ______Date: ______

Statement of support from Sponsor Organisation

A Sponsor organisationis required to pledge for a non constituted group. The sponsor organisation must be a constituted group and be willing to allow small grant to be paid into their bank account to be held on behalf of the group.

Name
Job Title(if applicable)
How do you know this organisation or group
Address for correspondence (including postcode)
Daytime telephone number
E-Mail address (if applicable)
I can confirm that I have read this application and support the request for funding and that I am suitably qualified to act as a sponsor for this initiative. I am willing to be contacted to discuss this application further. I am also willing to comment on the grant at a later date if this application is successful, and to provide a short written report if required.
Signed: ______Date: ______
Name (please print): ______

Statement of Support by Independent Referee

Your application needs the support of an independent referee who knows your organisation and its work. Please note that referees may be contacted to confirm their knowledge of your work.

Referees must not be an employee or office bearer of your organisation; anyone related to an employee or office bearer of your organisation; someone who has been an employee or office bearer in the past two years or someone who will directly benefit from the grant.

You must attach this section - signed by your referee - to your application.

Name
Job Title(if applicable)
How do you know this organisation or group
Address for correspondence (including postcode)
Daytime telephone number
E-Mail address (if applicable)
I can confirm thatI have read this application and support the request for funding and that I am suitably qualified to act as a referee for this initiative. I am willing to be contacted to discuss this application further. I am also willing to comment on the grant at a later date if this application is successful, and to provide a short written report if required.
Signed: ______Date: ______
Name (please print): ______

Please clearly mark your locality on the envelope and send completed form:

C/o Gus Collins

South Ayrshire Health and Social Care Partnership

South Ayrshire Council

County Buildings

Wellington Square

Ayr KA7 1DR

For Office Use Only

Checklist of required supporting evidence

Constitution Memorandum/Articles of Association

Bank Statement Referee Statement
Checklist of required supporting evidence for non constituted groups

Sponsor Organisation Statement Referee Statement
Comments
Date Application received
Reference number
Date Application Processed
Outcome

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