/ Application Form – Part A 2015/2016(with a potential extension period of up to 24 months)

Belfast Outcomes Group

Family Support

Funding Application

The following documentation should be completed and returned to the BHSCT, Early Intervention Support Team:

by email to:

AND

an original signed copy with supporting documents to be forwarded to:

Early Intervention Support Team, 124 Stewartstown Road, Belfast, BT11 9JQ

All completed documentation and information must be received by 12 noon on Thursday 12 March 2015. (Late applications will not be considered)

This Application Formhas 2 Parts

Part A must be completed onceby all organisations who are applying for funding under the Belfast Outcomes Group, administered by Belfast Health & Social Care Trust.

Part Bmust be completed separately in connection for each intervention method applied for. For example, when applying for funding under the intervention method of Home Visiting you will complete both Part A and Part B of the form. However, should you also wish to apply under the intervention method of mentoring, you are required to complete an entirely new Part B.

1

/ Belfast Outcomes Group
Family Support
Funding Application

PART A – MANDATORY

Please answer all questions

ORGANISATION DETAILS
Name of Organisation:
Address:
Postcode:
Telephone No:
Fax No:
Email Address:
Name of Chairperson:
Address:
Postcode:
Telephone No:
Fax No:
Email Address:
Name of Secretary:
Address:
Postcode:
Telephone No:
Fax No:
Email Address:
Committee Membership Names:
STATUS OF ORGANISATION
Registered Charity No:
Date of Registration:
Company Limited by Guarantee No:
Date of Registration
LEGAL/STAFFING REQUIREMENTS
Please confirm that all staff have been registered as approved with ACCESS NI. / Yes: / No:
Where Registration with RQIA is required, please confirm that the registration has been completed: / Yes: / No:
In keeping with the Race Relations (NI) Order 1997, has your organisation adopted a race relations policy? / Yes: / No:
Please confirm compliance with ‘Safeguarding Vulnerable Groups (NI) NI Order 2007 (as amended by the Protection of Freedoms Act 2012) / Yes: / No:
Describe how your organisation will ensure that equality of opportunity exists among the nine groups of people specified in Section 75 of the Northern Ireland Act and that the Human Rights of any individual are not violated. (see included documentation)
Are volunteers used by your Organisation? / Yes: / No:
Is volunteering promoted in any way? / Yes: / No:
If appropriate please give further information (for example the number of volunteers, type of work in which they are involved).
Please specify your quality indicators:
Please specify what training programmes are provided directly or accessed for staff:
Explain how users are involved in service planning:
Does the organisation comply with Health and Safety Regulations? / Yes: / No:
Does the organisation have employee and public liability insurance, minimum £10m for employee and minimum of £5m public liability which is valid for the period of requested funding? / Yes: / No:
FINANCIAL REQUIREMENTS
Please confirm the names and designation of the two unrelated authorised cheque signatories:
Name: / Designation:
Name: / Designation:
Name of certified Auditors:
Address:
Postcode:
Telephone No:
Fax No:
Email Address:

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/ Belfast Outcomes Group
Family Support
Funding Application
PART A

Declaration

I declare that :

  • All the information given is correct
  • The estimated costs have been approved by the Organisation’s Management Committee against fraudulent or corrupt actions.
  • The funding will be used for the purposes which are specified in this document.

  • No changes will be made to any of the proposals without the approval of the Trust.
  • If information given is inaccurate or incomplete, the funding will be returned to the Trust.

Signed on behalf of: / Organisation Name:
By (both) / Chairperson/ Chief Executive / Director/ Secretary
Name (Print)
Signature
Date