2015-18 APPLICATION FORM

for currently funded Organisations under the

Sport and Recreation Sustainability Program

BEFORE YOU START

Please read the Sport and Recreation Sustainability Program Guidelines before commencing this application form. Any questions regarding this grant program or your application, please contact a Funding Services Consultant 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
If you are unsure, please contact a Funding Services Consultant on 7424 7708. /
  1. Has your organisation received funding under this program before?
YES NO (Please use the New Applicant Application Form)
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Indicate your compliance and ongoing obligations to child safety. /
  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
Indicate whether you have updated MyRecSport /
  1. Please indicate whether you have updated MyRecSport with ;
  • most recent financial records,
  • the data in Our Industry Profile Section,
  • uploaded the required policy and operational documents;
  • A Member Protection Policy (including child safe policy)
  • A Hot Weather Policy
  • An ASADA Policy (if relevant)
  • A Match Fixing Policy (if relevant)
  • A Disability Action Plan ( if not, agree to develop one by 31 December 2015)
YES NO
Only complete if you wish the Grant Contact person to be different to the person listed on MyRecSport. / Title: / Eg. Miss
First Name:
Surname:
Position:
Phone: (b/hours) / (08)
Mobile:
Email:
APPLICANT DECLARATION
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 27 January 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 27 January 2015
Telephone: (08) 7424 7708 Web: ors.sa.gov.au
It is anticipated that applicants will be notified of the outcome by late April 2015

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