2015-18 APPLICATION FORM

for New Applicants of the

Sport and Recreation Sustainability Program

BEFORE YOU START

Please contact a Funding Services Consultant prior to completing this form to determine suitability for funding. Phone: 7424 7708 or E-mail:

Advice Notes /
  1. Name of Organisation: (as it appears on your Certificate of Incorporation)

Please enter the legal name of your organisation
Organisations previously funded can complete another application form, as all details should be available from MyRecSport. /
  1. Has your organisation received 2015-16 funding under this program?
YES(Please use the Currently Funded Application Form)
NO(Please continue)
All application correspondence will be directed to the person via the postal/email address provided. /
  1. Name and details of contact person for this application:

Title: / Eg. Mr
First Name:
Surname:
Position:
Phone: (b/hours) / (08)
Mobile:
Email:
Please use an address that will be checked at least weekly. /
  1. Postal address of your organisation:

Address:
Suburb/Town:
Postcode:
If you are unsure of your ABN, please visit the Australian Business Register at /
  1. Does your organisation have an Australian Business Number (ABN)?

If you are unsure, please call the Australian Taxation Office on
13 72 26. /
  1. Is your organisation GST registered?
YES NO(see Guidelines for information on Grants and GST)
APPLICANT PLANS/REGULATION/POLICY INFORMATION
Organisations are required to have a current Strategic Plan for further assistance visit:
ors.sa.gov.au /
  1. Has your organisation a current strategic plan?
YES NO
BEING DEVELOPED
Organisations are required to have a Child Safe Compliance Statement for further assistance visit:
ors.sa.gov.au /
  1. Has your organisation lodged a Child Safe Compliance statement with the Department of Education and Child Development and is aware of its obligations to maintain a child safe environment?
YES NO
BEING SOUGHT NOT APPLICABLE
Organisations are required to have a Member Protection Policy for further assistance visit:
ors.sa.gov.au /
  1. Has your organisation developed a Member Protection Policy (including child safe policy)?
YES NO
BEING DEVELOPED NOT APPLICABLE
Organisations are required to have a Hot Weather Policy for further assistance visit:
sma.org.au /
  1. Has your organisation developed a Hot Weather Policy?
YES NO
BEING DEVELOPED NOT APPLICABLE
Organisations are required to have a Member Protection Policy for further assistance visit:
ors.sa.gov.au /
  1. Has your organisation developed an ASADA Policy (if relevant)?
YES NO
BEING DEVELOPED NOT APPLICABLE
Organisations are required to have a Match Fixing Policy for further assistance visit:
ors.sa.gov.au /
  1. Has your organisation developed a Match Fixing Policy (if relevant)?
YES NO
BEING DEVELOPED NOT APPLICABLE
Organisations will be required to have a Disability Action Plan by 30 June 2016 for further assistance visit:
ors.sa.gov.au /
  1. Has your organisation developed a Disability Action Plan?
YES NO
BEING DEVELOPED
APPLICANT PROFILE INFORMATION
Members who have access to the full range of programs and services offered by the organisation or their affiliated club or association, as a participant, coach or official. This type of member typically pays full registration fee and participates actively in programs and services. /
  1. How many full active members does your organisation have:

Member/participants who have access to a limited range of programs and services offered by the organisation or their affiliated club or association as a participant. This type of member/participant typically pays a lesser registration fee and participates in programs and services rather than regular competitions. /
  1. How many Program Participants does your organisation have:

Event participants pay a fee per event to participate in the activity and receive limited other services (eg: newsletter) from the organisation. This type of participant pays no formal membership fee and may not have access to programs and services of State organisation. /
  1. How many Event Participants does your organisation have:

School Managed Competition participants are involved in events, competitions or programs organised primarily by schools which are not directly affiliated with State organisations. /
  1. How many School Managed Competition Participants does your organisation have:

School Delivered Program participants are involved in regular competitions, programs and championship events organised by state organisations which may be at school facilities. /
  1. How many School Delivered Program Participants does your organisation have:

Associations who are in turn representative of other clubs or organisations. /
  1. How many affiliated associations does your organisation have:

The number of affiliated Clubs. /
  1. How many affiliated clubs do your organisations represent:

Period eg. 1 July 2013 to 30 June 2014
Income is also referred to as Revenue.
Income or Revenues are inflows or other enhancements of assets or decreases of liabilities that result in increases in equity, other than those relating to contributions from equity participants. /
  1. Please provide the most recent three years of annual financial income of your organisation:

Income: / $ / Period:
Income: / $ / Period:
Income: / $ / Period:
APPLICANT DECLARATION
Final checklist before submitting your application
We have completed all relevant sections of this application form
Instructions
  1. The declarations below must be read and signed by two authorised representatives of your organisation
  2. At least one representative must be a member of the Board / Management Committee.

Declaration by authorised persons
I make the following declaration:
  1. I am duly authorised by the organisation to prepare and submit this application
  2. This organisation is eligible to apply for funding in accordance with the eligibility criteria in the Sport and Recreation Sustainability Program Funding Guidelines
  3. The responses in this application and all supporting documents provided are to the best of my knowledge true and correct
  4. I understand that the Office for Recreation and Sport may disclose the information provided in this application to other Government agencies, Local Government, reviewers and staff assisting with the administration or promotion of State Government Grant Schemes
  5. I understand that information contained within this application may be made public. Please refer to the program guidelines for more information.

Signature 1: / Signature 2:
Date: / Date:
Name: / Name:
Position: / Position:
Please forward this completed application and all attachments to:
BY POST:
Applications post marked on or before the closing time and date will be accepted.
Sport and Recreation Sustainability Program
Office for Recreation and Sport
PO Box 219
BROOKLYN PARK SA 5032 / IN PERSON:
Hand delivered applications must be received by 5.15pm Tuesday 27January 2015.
Sport and Recreation Sustainability Program
Office for Recreation and Sport
27 Valetta Road
KIDMAN PARK SA 5025
LATE APPLICATIONS MAY NOT BE ELIGIBLE FOR FUNDING CONSIDERATION
Applications close 5:15pm Tuesday 27January 2015
Telephone: (08) 7424 7708 Web: Hors.sa.gov.auUH
It is anticipated that applicants will be notified of the outcome by lateApril 2015

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