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Application Form for Kiwi Outreach Grant (to be vetted by Pastor/Minister or Budget Advisor)
Section A – Personal Details
- Kiwi Outreach Partner Applied too: Cambridge Baptist, Bridges, Elam, St Andrews, Cambridge Community House (Please Circle)
Applicant’s Details
- First Name: ……………………………………….. Last Name……………………………………
Address: …………………………………………………………………………………………………….
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Suburb: …………………………… Cambridge Post Code:……………..
Email address: …………………………………………………………………………………………….
Telephone: Business :( ) ………………………….. Home: ( ) ……………………………….
Mobile: ( ) …………………………………
Date of Birth: ………/…………/………… Age: ………………………… Male/Female
Ethnicity:…European / Maori / Asian / Pacific peoples / Middle Eastern/Latin American/African / Other
3.Age (or range of ages) of the children in your care?
Full Name / M/F / Age / Resides with childY/N
Section B – Assistance Required
4.Describe exactly the assistance or item (see Kiwi Outreach Guidelines) you require and how the items or grant are to be used:
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5.Please describe a little about your present circumstances - including any illness or disability that may be relevant to this application
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6.What difference will this grant or item make?
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7.Do you live in your own home or are you currently renting a property? ……………………….
Mortgage/rent payments $ ……………………………….. Weekly/fortnightly/monthly
8. What is your main source of income? ......
9.What is your weekly/fortnightly surplus after deducting expenses? ......
10.Have you ever applied to Kiwi Outreach before: Yes/No
If Yes, please give dates and details: ………….…....……………………………………………
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11.Have you applied to any other source for this funding? Yes/No
If Yes, please give dates and details:
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12.Do you have any convictions for fraud or dishonesty (if so please provide details)? Yes/No......
12.Do you give permission for your application details (with surnames removed) to be used in Kiwi Outreach Promotions. This helps Kiwi Outreach to raise funds from the public for current and future grants. .
Yes/No
Email address:
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Section C
a)I believe the above information to be true and correct. I understand that this information will be used by Kiwi Outreach to establish our need for a grant.
b)Should our application be successful I/we accept Kiwi Outreach may, in its sole discretion,
use any information relating to the application or the applicant for the purpose of publicity to
raise awareness of Kiwi Outreach and the assistance that it provides and the applicant consents to such use.
c)Your contact details will be put on our database to keep you up to date with Kiwi Outreach activities. If you do not wish to be contacted in the future, please advise our office.
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Applicant
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Date