Welwyn Hatfield Community Safety Initiative

St Albans District Health & Wellbeing Grants Application Form 2016/17

Name of Organisation
Lead Contact
Address
Phone Number
Email address
3. Project Name
4. Describe your project in approximately 20 words
5. Amount requested - maximum amount is £3,000
6. Total project cost
7. Project details and plan: Project details – what is your project, where is it, who is it for, why is it needed? Project plan - List activities and time plan.
8. Does your project meet the three essential criteria for funding?
Criteria / Yes / No
Does your project support one of our three priority areas of Increasing Physical Activity, Improving mental health and wellbeing and Reducing the harm from alcohol.
Does the project contribute to reducing health inequalities in the District
Is your project an innovative way of improving public health outcomes in the District?
9. How will your project/activities meet the criteria that you have marked “yes” in Q8
Provide evidence for each criterion
10. Outcomes and how will you measure success? (see below – please add further outcomes if required)
Description of Outcome 1:
How will you measure it?
Description of Outcome 2:
How will you measure it?
Description of Outcome 3:
How will you measure it?
11. Please explain how you know people in your community want or need your project/activities and what evidence you have collected to demonstrate this.
12. How do you plan on spending your grant? Please include a budget plan here or submit a separate, detailed budget plan and quotes for capital items
13. Approximately how many people will benefit from this grant?
14. What measures have you taken to ensure the project’s continuity? Or is this a one-off project?
15. When will the project be completed?
16. Does the project require funding from other sources? / Yes / No
If yes, please state where from and if it has been secured.
Declaration
The information given on this application form is correct to the best of my knowledge.
We give consent for the above information to be stored and held in accordance with the Data Protection Act 1998 and used by St Albans District Council and its agents. We have ensured that all names and contacts agree to have their details made available.
Name (please print)
Date

Please return this form by Friday 1st July 2016

Completed applications must be emailed to: