Grant application form January/June 2011

Seeking ESC support for a COURSE/MEETING

The ESC will provide funding to support a regional or local course or meeting within Europe related to the aims of the ESC.
Application / Please use this application form. Note sections with a maximum word count. Forms will be returned if the word count is exceeded.
Who can apply? / Applicants must be paid-up ESC members.
Condition / At least one speaker must be a member of the ESC Board, with their expenses paid out of the grant.
Deadline / Applications MUST be received at ESC Central office by 30 June 2011.
Budget / 5,000 euro for applications received between 1 January and 30 June.The ESC may not be in a position to fully fund all applications.
Name of applicant / DR.George Tsertsvadze
Job title / «Comprehensive Abortion Care (CAC)»
Trainings
Address / 18 S.Chiqovani str,flate20, Tbilisi,0171, Georgia
Tel no. / +99599553047
E-mail /
Date of submission of this form / 20.06.11
Name of the person responsible for the course/meeting (If different to the person named in box A) / Nodar Gvetadze
Contact details of the person noted in this box B:
name of person, job title, address, tel no. email / General director of«Healthy life».
T:+99599569726

Title of the course/meeting
Comprehensive description of the course/meeting. (Max 200 words)
Georgia has one of the highest abortion rates in the world. The Program can strengthen access to and availability and quality of Comprehensive Abortion Care (CAC) (Medical abortion, MVA and postabortion contraception) .
Our purpose is to educate Maternity House staff in Comprehensive Abrtion care(Medical abortion, MVA and postabortion contraception), consultation skills and regulate relations between provider-client.
When would it start / finish? (Max 20 words)
Start 10.01.2012 and finish: 28.02.2012
Where will it take place – country / town, establishment? (Max 20 words)
1.  Tbilisi(Georgia)- 3 trainings
2.  Batumi(Georgia)- 1 trainings
3.  Kutaisi(Georgia)- 1trainings
Objectives and needs identified. Who will be the audience? (Max 20 words)
Our purpose is to educate Maternity House staff in Comprehensive Abrtion care(Medical abortion, MVA and postabortion contraception), consultation skills and regulate relations between provider-client.
Sector in the area of contraception, sexual and reproductive health.
Safe abortion, post abortion care, postabortion contraception
What outcomes will be measured? List. (Max 20 words)
The project team expects that as a result of these activities, the following results will be achieved:
·  Approximately 100 doctors from all Regions will be trained in. Comprehensive Abortion Care (CAC)
·  Our main goal is to improve the quality of reproductive life of population through establishing high quality safe abortion and post abortion services.
·  MA and MVA, PAC services.
Post abortion consultation in FP methods
Do you foresee any reasons why this meeting may not happen? (Max 20 words)
No
Are there other partners or organisations supporting this same course/meeting? If so, list.
“Gynuity health Project”
Have you requested funding from anyone else for this course/meeting? (If yes, please give details of all funding sources you have approached) (Max 20 words)
How much money are you requesting? A detailed budget must be provided.
(Max 50 words)
January-February 2012
Line Items / Account code / Unit cost / Qty / Unit / Duration / Unit / Amount
1.project manager 300 1 2 month 600 euro
2.logistic assistant 150 1 2 month 300 euro
3.trainer/consultant 100 2 position 10 days 2000euro
4.training hall rent 50 10 days 500 euro
5.communication and travel 1100 euro
6.total 4500 euro
Have you already obtained any funding towards this course/meeting? (If yes or still awaiting a response, please give details) (Max 20 words)
Who will oversee the budget & keep accounts?
George tsertsvadze

I / We, as responsible agents for this project, agree to the following 6 points:

I/We agree that all monies will be spent appropriately / yes
I/We agree to advise you at the earliest time if this course/meeting is delayed or cancelled / yes
I/We agree to provide a report to the Board of Directors of the ESC within 6 months of the end of the course/meeting / yes
I/We agree to present the ESC treasurer with a detailed budget at the end of the course/meeting. / yes
/We agree that if you need to make any significant changes to the funding of the project after it has been awarded, I/we will advise the ESC Treasurer. / yes
I/We agree to acknowledge the ESC as a donor in any publications and oral communications resulting from this course /meeting. / yes

Signed G.Tsertsvadze Date20

Name

Please return this form (by email) to:

ESC Central Office

Opalfeneweg 3

B-1740 Ternat, Belgium

Tel +32 2 582 08 52

Fax +32 2 582 55 15

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