VCSE Health and Wellbeing Alliance

2017-18

Application form

Application form

We encourage you to read the information pack published alongside this application form before answering the questions.

Your completed form should be e-mailed to by 12:00pm on 22 February 2017. Applications received after this time will not be accepted.

If you have any queries please contact:

  • Email:
  • Telephone: 0113 254 5450

A - Your contact details

Organisation name
Main contact first name
Main contact last name
Main contact position
Main contact email address
Contact telephone number

B - Joint / consortium / partnership details

If this is a joint / consortium / partnership bid please list the names of all organisations included here. If a single bid please enter ‘not applicable’.

Please confirm that you have an agreed partnership agreement, memorandum of understanding or similar that governs your partnership or consortia. Please attach it to this application.

C - Organisation profile – this is the applicant organisation’s details

Legal name (if different)
Operating name (if different)
Abbreviation (if applicable)
Telephone number
Chief Executive
Address
Charitable status
(Please select one) / Charity
Exempt charity
Not a charity
Charity number
Legal structure
(Please select one) / Limited Company
Community Interest Company
Industrial and Provident Society
Unincorporated association
Other
Registration number
Regulatory body (where applicable) / Charity Commission
Companies House
CIC Regulator
Financial Services Authority
Care Quality Commission
Area of operation or benefit
Does your organisation provide a service similar to that provided by the NHS or by local authority social services? / Yes
No

D – Your contribution to the VCSE Health and Wellbeing Alliance

In the boxes below describe how your organisation can contribute to the VCSE Health and Wellbeing Programme and the health and care priorities of the Department of Health, NHS England and Public Health England (summarised in the application pack).

  1. Describe the part of the sector that your organisation represents (50 words).

To note: you should refer to page 9 of the application pack and note that if your organisation does not represent the groups/types of organisations outlined you must provide additional information (requirements set out in page 12 of the pack)

  1. Explain how your organisation is able to act on behalf of the community or part of the sector that it represents (300 words).
  1. Describe the breadth and depth of your organisation’s memberships and networks in the voluntary and community sectors in England (500 words).

Please include information about:

  • Other organisations that you work with and how you work with them
  • Your geographic reach
  • The range and type of people you work with
  • Particular successes demonstrated from your reach

To note: you are also asked to provide supporting references as part of your additional information

  1. Provide evidence of your organisation’s experience of working in partnership and co-producing approaches (300 words)
  1. Describe and provide evidence about how your organisation is able to engage with the part of the sector it represents (350 words).

Please describe and provide evidence about:

  • How you will gather views and feedback
  • Your proposed structures, mechanisms and strategies for disseminating information
  1. Describe and provide evidence of your organisation’s specific expertise and strength in the areas of health, public health, wellbeing and care (300 words).
  1. Describe and provide evidence about how your organisation is well placed to strategically consider and advise on how wider system priorities, emerging issues and policies may impact on equality and health inequalities (300 words).
  1. Explain how your organisation would be well placed to respond to the specific pieces of work that will be identified throughout the year to support the requirements and strategic objectives of system partner organisations (300 words).
  1. Any other supporting information and evidence that the panel should consider including anything which addresses the desirable criteria outlined in the application pack (250 words).

E – Board of Trustees approval

Is a member of the Board of trustees/Directors aware and content for this application to be made?

Provide his/her contact details below.

F – Additional Information requirements

You must also provide the following information.

For established organisations:

Your most recent Annual Report and final audited accounts
Equal Opportunities Policy Statement
Health & Safety Policy Statement
Staffing structure for the organisation highlighting which roles would contribute to the programme
Your organisation’s Business Plan
Copy of Memorandum and Articles of Association or constitution / governing document
A budget plan, including a breakdown of costs (see template)
References to support your reach into the sector

In addition, for partnership or consortia applications you would need to provide:

Details of the partnership or consortia arrangements including governance
Confirmation from each organisation involved of their commitment to and role in the partnership / consortia – this could include a letter of support
Confirmation of which organisation would be acting as the lead or accountable body

Please use the box below to add any comments or queries.

If you do not have electronic copies of your annual report and final accounts and they are not available through the Charity Commission website you should send hard copies to:

Grants Hub

Department of Health

2N14 Quarry House

Quarry Hill

Leeds

LS2 7UE