SOMERSET SMOKEFREE SPORTS CLUB GRANT

For more information please contact Andrew Ridgewell on 01749 344949. Please write clearly in black.

1. Contact Details

Name of the organisation

Address of the organisation

Post Code:

Main contact (This should be a person closely involved who can discuss the application)

Name

Position held in the organisation

Contact address (if different from above address)

Post Code:

Daytime phone number E-mail address

2. Is your organisation a registered charity? / Yes / No
If yes, what is the registered charity number?
3. Do you have a Constitution or set of rules?
(You will need to provide a copy – see checklist) / Yes / No

4. How many members do you have?

Young people under 16 years / Adults

5. How many people are involved in running your club? (You will need to send a list of committee members – see checklist)

Management Committee Members / Full time staff
Part-time Staff / Volunteers

6. You will need to ensure that all members, parents and visitors to the club are aware of the Smokefree Sports Policy (when youth activities are taking place). Please select how you plan to do this:

Pitch-side signs / Verbal announcements
Newsletter / Website
Stationery / Other (please explain below)

7. You will need to ensure that at least one coach attends a free intervention training session, run by the Somerset Activity and Sports Partnership and Somerset County Council. Please indicate below which session they would be able to attend. All sessions will commence at 6pm and we aim to finish between 8pm and 8.30pm. Light refreshments will be provided.

Yeovil/Bruton 21st June 2016 / Taunton/Wellington 28th June 2016

8. Please give name and contact details of the coach(es) who will be attending the above training session. Please ensure you include mobile numbers in the event of cancellation due to bad weather.

9. We will request an evaluation of your adoption of a smokefree policy. Please select how you will gather the information in order to provide this.

Case studies / Focus Groups
Feedback from young people (questionnaires/surveys etc) / Statistics
Photographs/Videos / Other (please explain below)
10. Are you happy to take part in any publicity? / Yes / No

11. Your grant will be released following successful completion of the training session. We will pay the funds directly to your account. Please give details below.

Your bank account / Account Name
Bank/Building Society Name
Account Number
Sort Code
How many signatures do your cheques require?

CHECKLIST

We cannot process your application unless you have:

Answered every question

Signed the form

Enclosed your club’s set of rules/constitution

Enclosed a copy of your child protection/vulnerable adults policy

Enclosed a list of management committee members

DECLARATION

I am authorised to make the application on behalf of the above organisation and confirm that this information is correct.

I confirm that the club will adopt a Smokefree Sports Club Policy when youth sports activities are taking place. (An example policy will be provided to help you.)

I confirm that at least one coach from the club will attend a Smokefree Sports Brief Intervention Training Course run by the Somerset Activity and Sports Partnership and Somerset County Council.

I confirm that I will provide an evaluation of the project to Somerset Community Foundation.

Signed: / Date:

REMEMBER TO KEEP A COPY OF THIS FORM FOR YOUR RECORDS

Please send your completed form and enclosures to:

SOMERSET COMMUNITY FOUNDATION, YEOMAN HOUSE, ROYAL BATH & WEST SHOWGROUND

SHEPTON MALLET, SOMERSET BA4 6QN

Email: website: www.somersetcf.org.uk

Registered Charity No. 1094446