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Sponsorship Application Form for Aboriginal & Torres Strait Islander delegates to attend the jointly hosted 20th Chronic Disease Network Conference and 44th Public Health Association of Australia Annual Conference

APPLICATIONS CLOSE 17th JUNE 2016

Late and/or incomplete applications will not be considered or accepted for sponsorship funding

Sponsorships will be allocated based on applicants meeting the selection criteria below and also on the strength of their application. Each application will be considered individually.

SECTION 1:APPLICANT DETAILS

Name:
Position/Job Title:
Organisation:
Work Location/ State:
Telephone/ Mobile number:
Email address:
Manager’s email:
Manager’s phone number:

SECTION 2:SPONSORSHIP FINANCIAL DETAILS

Full sponsorship will include Full Conference Registration costs, Standard Accommodation costs and Standard Travel costs.

If you do not require some of these aspects to be covered for you, please indicate below:

  • AccommodationYes ☐No☐
  • And Travel costsYes ☐No☐

BE AWARE, SPONSORSHIP WILL NOT INCLUDE:

  • Meals (apart from conference catering)
  • Social events associated with the conference
  • Travel allowances

SECTION 3:ELIGIBILITY CRITERIA

Please indicate which of the following that applies to you:

☐ Aboriginal or Torres Strait Islander descent.

☐ Presenting an abstract / workshop / poster at the conference.

☐ Work or live in a rural or remote area.

☐ Employed in or represent a health service/program.

☐ Employed in or represent an Aboriginal and/or Torres Strait Islander health service or

organisation (e.g. a school or other community-controlled organisation).

☐Employed in or represent a direct service delivery role, preferably in chronic conditions in a government, non-government or community based health organisation.

☐I am studying health / education / community services.

☐Have approval from my Manager to attend the conference if I am sponsored.

Have you received funding to attend the CDN Conference before?

Yes☐No☐Which Year(s) ______

Have you tried to get funding to attend the 2016 conference from any other source?

Yes☐No☐

►If Yes,wereyou successful?Yes ☐ No ☐

► If Yes, Who did you apply to______

How much did you apply for? $______

SECTION 4:DISCUSSION

Please answer the following questions:

  1. Describe what you do in your job and how it relates to Chronic Conditions and Public Health. (Maximum 150 words)
  1. How will you use this experience to improve Chronic Conditions and Public Health in your organisation and/or community? (Maximum150 words)

SECTION 5:APPLICANTS AND MANAGERS AGREEMENT

If your application is successful:

  • An email confirming sponsorship will be sent prior to

8st July 2016

  • Please ensure you are available to attend the Conference

I understand and agree to the terms of sponsorship detailed within this application for sponsorship.

Name of applicant:Signed:

Dated:

I support the above applicant to attend the Conference in Alice Springs over the 18-21 September, 2016. I am aware that this sponsorshipwill cover registration, accommodation and travel costs only.

Name of Manager:Signed:

Dated:

CHECKLIST FOR COMPLETED APPLICATION / RETURN COMPLETED APPLICATION FORMS TO:
☐ Completed all 4 sections of the form
☐ Manger has signed form indicating
they approve your attendance at the
conference. / By 17th June 2016
No late or incomplete applications will be accepted
Email:
ANY QUESTIONS? Phone: (08) 8985 8173