PLEASE NOTE: Late Or Incomplete Application Forms Will Not Be Accepted

Sport NZ Hillary Expedition
2014 GRANT APPLICATION FORM

Please submit typed application only. Return the electronic or printed form to Sport NZ by 4pm, 2 October 2014 (please refer to the delivery details at the bottom of this form). The fields below are expandable and the space provided for information is the absolute minimum required.

PLEASE NOTE: Late or incomplete application forms will not be accepted.

OFFICE USE ONLY:

Team Name:

Application number:

Date received: Date acknowledged:

In submitting this applicationyou understand the following terms and conditions of applying:

All applications must be submitted on this form, no later than 4pm,Thursday 2 October 2014.
All applicants must be over the age of 18 years at time of application.
All applicants have read and agree to the terms of the 2014 Hillary Expedition criteria.
All information provided by the Team in the Hillary Expedition application form must be true and correct.
Individual team members can only be in a maximum of two teams applying in any one year.
It is unlikely that:
teams made up of individuals who were in successful expeditions in both of the last two funding rounds will be successful in this funding round
teams based overseas will be successful in this funding round
Successful applicants will be required to submit a comprehensive risk management plan to Sport NZ for approval. Payment will not be made until this plan has been approved by Sport NZ.
All applicants will be advised in writing whether they have been short listed or not byThursday 16 October 2014.
If requested, applicants must provide Sport NZ with any additional information as requested at any stage of the application process.
By applying, you agree that Sport NZ mayprofile your entry in the media for the purposes of promoting the Expedition. Sport NZ reserves the right to promote successful expeditions where appropriate. Promotional plans will be developed on selection of successful applicants.
Applicants accept Sport NZ’s right to develop and / or promote a documentary, film or similar production that follows the Expedition and that Sport NZ reserves the right to partner with a television network or production company to develop such a programme.
By applying, each team member of a successful application agrees to make themselves available to mentor future Hillary Expedition recipients, if requested by Sport NZ.
If no applicants meet the criteria sufficiently or to the satisfaction of the panel, Sport NZ reserves the right to not allocate the funding.
All short listed applicants will be advised directly in writing of the panel’s decision byFriday 12 December 2014and no further correspondence will be entered into with any unsuccessful applicants.
Entries will not be returned to applicants unless specifically requested. All unreturned applications will be disposed of securely.
The successful proposal will not necessarily be accepted in total. Changes may be negotiated prior to final contract signoff by Sport NZ or on the advice of peer reviewers and/or mentors.
Successful applicants must agree to reference checks prior to confirmation of selection.

We agree to the following conditions if we are funded by Sport NZ Hillary Expedition:

The contact person as specified in the original proposal is the main point of contact for communication between Sport NZ and the successful application in all matters related to the expedition.
Sport NZ reserves the right to amend the level of investment to successful applications if there are changes to the original proposal. Proposal changes include, but are not limited to team composition (size), individual team members (expertise, personnel, injury or financial hardship) and expedition objective.
To provide Sport NZ with an up-to-date project plan including comprehensive timetable, expedition milestones and detailed itinerary of the Expedition no later than one month before the commencement of their expedition.
To secure all necessary consents / permits / visas to ensure the lawfulness of our expedition before departure from NZ and to provide Sport NZ with copies of those.
To keep clear records of financial expenditure.
To submit to Sport NZ a written project report within 6 weeks after completion of the project, covering financial expenditure and the expedition itself is undertaken.
Expeditions must be completed within 18 months of notification that you are to receive a grant or by 30 June 2016.
To make ourselves available for interviews for promotional purposes by Sport NZ or media representatives before; during and after our expedition where possible and reasonable.
To make ourselves available to mentor future Hillary Expedition recipients.
That at least one team member (or representative) makes themselves available to attend the Sport NZ Hillary Expedition workshop

SECTION A:CONTACT DETAILS

A1. Team name:

A2. Who is the main contact person for all matters relating to this application?

Name
Postal address
City / Town
Physical address (if different from above)
Phone
Email
Website address

A3. Have you or any member of your team applied previously for a Hillary Expedition grant?

YES NO

If yes, please provide details of any of your expeditions that were short-listed?

A4. Please provide details of all team members (including support crew):

Name
Postal address
City / Town
Phone
Email
Name
Postal address
City / Town
Phone
Email
Name
Postal address
City / Town
Phone
Email
Name
Postal address
City / Town
Phone
Email
Name
Postal address
City / Town
Phone
Email
Name
Postal address
City / Town
Phone
Email

SECTION B:EXPEDITION OUTLINE

B1. Please provide specific details of your proposed expedition

Where is the expedition to take place?

When is the expedition scheduled to commence?

What is the duration of the expedition?

B2. Please provide a brief summary (up to 200 words maximum) of why you and your team should receive a Hillary Expedition grant?

B3. What are your expedition aims & objective(s)?

B4. How will a Hillary Expedition grant help you achieve your aims and objectives as outlined above?

B5. How will you ensure that your proposal contributes to the following Sport NZHillary Expedition high level outcomes?

raise the profile of outdoor recreation / adventure

encourage Kiwis to try outdoor adventures

create inspirational role models

position New Zealanders as innovative

B6. Please provide details of your team members’ relevant experience?

SECTION C:RISK MANAGEMENT AND ENVIRONMENTAL IMPACT

Short listed applicants will be subject to a rigorous peer review and risk management and environmental impact assessment to ensure best practice and safety standards are met.

Shouldyour expedition be selected for a Hillary Expedition grant you will be required to submit comprehensive risk management and environmental impact plans prior to commencement of your expedition. All short-listed applicants will be advised in writing whether they have been successful or not byFriday 12 December 2014and that a copy of their risk management and environmental impact plans are required to Sport NZ no later thansix weeks prior to the departure of their expedition and prior to payment of the Hillary Expedition grant being made.

C1. Please provide a brief explanation of your plans for risk management and environmental impact.

SECTION D:GOVERNMENT APPROVALS

D1. What governmental requirements and approvals are required in order for the expedition to proceed?

Notecopies of these must be provided to Sport NZ prior to departure

SECTION E:FINANCIAL INFORMATION

FINANCIAL SECTION

E1. Please provide a detailed budget for all aspects of the Expedition here:

Item / Comment / Unit Cost NZ / No. Units / Total NZ Costs
Travel (including taxes)
Accommodation
Equipment
Insurance
Liaison expenses
Permits
Meals / Food
Medication
Deposits
Communication
Expedition fees
Clothing
Marketing
Sundry – please specify
Total Expedition Budget
INCOME / $ APPLIED FOR / DECISION DATE / $ GRANTED
Sport NZ
Own contribution
Other funders (please list)
TOTAL

E2. If you do not receive the level of funding sought from Sport NZ or other funders can your expedition still go ahead? If yes, please indicate what impact a reduction in available funds would have on your expedition

E3. Will you still be able to achieve your goals and objectives with reduced funding?

E4.If your expedition receives a Hillary Expedition grant, Sport NZ will pay by direct credit only.

Please record thedetails of your expedition’s main operating bank account into which the Hillary Expedition grant will be deposited.

Note

Payment will only be made once the signed contract has been returned;your risk management plan has received external approval and mentor sign off and will be scheduled as follows:

2/3 on signing of schedule, risk management plan and mentor sign off
1/3 subject to all Sport NZ conditions being met (this will be determined on an individual basis)

Account name
Banking institution the account is with
Account number

E5. Are you GST registered? YES NO

GST number:

SECTION F: REFERENCES

F1. Please list two or three references for Sport NZ to contact (please include daytime contact numbers and email details)

Name
Phone
Email
Relationship
Name
Postal address
City / Town
Phone
Email
Name
Postal address
City / Town
Phone
Email

SECTION G: ACCEPTANCE

G1. Agreement of all team members to all the terms and conditions outlined above:

Please tick applicant declaration

 This signals that all information provided by the team in the application above is true and correct.

 This signals that the main contact person or team leader of the expedition agrees to all the terms and conditions outlined in the application above.

Name
Signed
Date

 This signals that each team member of the team agrees to the terms and conditions outline in the application above.

Name
Signed
Date
Name
Signed
Date
Name
Signed
Date
Name
Signed
Date
Name
Signed
Date
Name
Signed
Date
Name
Signed
Date

Please note: that applications must be signed by the main contact person or team leader. For those team members who do not reside in the same town/city, Sport NZ will accept email confirmation of the terms and conditions of the application.

SECTION H: APPLICATIONS

H1. Applications can be submitted by email, post or delivered to Sport NZ’s office in person.

Email -

Post

Sport NZ

PO Box 2251

WELLINGTON 6140

Attn: Fiona Ramsay

Deliver in person

Sport NZ

Ground Floor

86 Customhouse Quay

WELLINGTON

Attn: Fiona Ramsay

Please note that entries will not be returned to applicants.

2014 Sport NZ Hillary Expedition Grant Application Form