ErewashPublic Health Locality Fund

Grant Application Form 2016-17

Project title
Receiving organisation
Receiving organisation named lead
Contact email/number
Date Submitted
  1. Brief Outline

Give a brief description of your project
  1. Aims/Objectives

What are the aims and objectives of your project ?
  1. Priorities and evidence of need

Please describe the priorities your project aims to address and how and why you have identified these as priorities for Erewash (for instance local intelligence, health/other data, demand for services)
  1. Impact/outcomes

Tick the outcome/s that reflect the change or difference your project will make. It is essential that your project meets at least one of the outcomes to be considered for a grant but you do not have to tick all of the boxes*
Improved emotional health, wellbeing and relationships (individuals) / Increased support for people with long term conditions
Increased levels of activity (individuals) / Reduction in fuel poverty and winter deaths
Reduction in falls and improvement in mobility / Improve diet nutrition and weight management
Improved community cohesion and reduction in social isolation / Increased access to services
Increased opportunities for education, employment, career and training skills / Awareness raising of the dangers of alcohol and drugs
Reduction in poverty (Inc. homelessness, debt management, food banks) / Reduction in crime, anti-social behaviour and/or domestic violence
Reduction in smoking / Improved Sexual health and/or reduction in teenage pregnancy
Other, please specify:
*Please note your proposed outcomes should inform the way you project/intervention is evaluated.
  1. Monitoring/Evaluation

Outline how you intend to monitor and evaluate your project. Please note acceptance of the grant implies you agree to provide monitoring information.
  1. Beneficiaries

Give details on who will be targeted, the location* of the places where your project will happen and the total number of people you think will benefit
*Please note projects that target areas of high need will be prioritised
  1. Timetable

Please give a proposed start and finish date for the project or outline proposed timetable
  1. Publicity/promotion

Give details of how you will promote or publicise your project
  1. Sustainability

If applicable, outline any consideration given to making this project sustainable and how this might be achieved
  1. Budget

Financial breakdown of the project - Costs / £
Total
Funding for this project from other sources (including contributions from reserves/other funding applications)
Balance Requested from Public Health Locality Funding
What other grant applications have you made in relation to this project?
Applied to / Amount / Outcome (if known)
Please return your completed form by email to Lianne Barnes by 12noon 29th April.
If this is not possible you can post it to us –Lianne Barnes, Public Health Development Worker – Erewash, Godkin House, 2 Park Road, Ripley, Derbyshire, DE5 3EF
Please get in touch if you have any queries about completing this form.

Erewash Locality Fund Application Form 2016