Consumer Leadership Development Grant: 2016application form

Consumer leadership development grants (CLDG) are available to assist consumer participation in leadership development learning activities. Any organisation funded by the Disability Support Servicegroup of the Ministry of Healthcan apply either on behalf of consumers of their services, or as sponsors of other consumers. For the purposes of this grant, ‘consumers’ also includes family/whanau of a person with a disability. At the end of the learning activity, organisations must provide afinal reportto an acceptable standard before submitting any further Disability Workforce Development grant applications.

If you have any questions please email prior to submitting this application.

Eligibility

Is your organisation funded by the Ministry of Health to provide disability support services? / Yes/No
Are all the consumer applicants eligible to receive disability support services funded by the Ministry of Health? / Yes/No
Are all the consumer applicants New Zealand citizens or permanent residents? / Yes/No
Does your organisation agree to support the proposed consumer participant/s to complete the learning activity? / Yes/No
Will the learning activity be delivered in New Zealand? / Yes/No
Organisational details
Legal name: / Trading name:
Ministry of Health contract number:
Physical address:
Postal address:
Contact details
Contact person: / Role:
Email: / Phone (incl. cell phone):
Alternative contact person: / Role:
Email: / Phone (incl. cell phone):
Application details
  1. Title of the learning activity:

  1. Name of the organisation delivering the learning activity:

  1. Name of person/s facilitating the learning activity:

  1. Activity start date:
/
  1. End date:

  1. Number of participants in this application:

  1. Give a brief outline of the learning activity, describing the course or programme content:

  1. How will the learning activity be delivered? Include the number of sessions, the method of delivery, and locations where activity will occur.

  1. How does the learning activity relate to the aims of the Consumer Leadership DevelopmentGrant or the grant priority areas? See the Consumer Leadership Development Grant information on the website for these priority areas.
  1. Describe which of the Let’s get real DisabilityReal Skills the participants will acquire, or improve, as a result of completing the courses/training outlined in the application.

  1. What support will be available for participants to complete the learning activity?

  1. What opportunities will participants have to apply their learning to benefit disabled people or the disability sector?

  1. What experience or expertise does the facilitator have in delivering learning activities in the disability sector?

  1. If the facilitator does not have experience in the disability sector, please indicate why you have chosen this facilitator and how you will ensure the facilitation will be appropriate for the disability workforce?

  1. Are disabled people included in the development of the learning activity or the delivery of the training?Please describe:

  1. If disabled people are not involved in the development or delivery of the training how will you ensure a consumer perspective is included in the learning activity?

Budget details

Please provideallcost details inclusive of GST.

Registration fees (external courses) / Cost per person / X / No.people / =
Facilitator fees* / Cost per hour / X / No. hours / =
Facilitator travel/accommodation/meals / =
Venue hire / Cost per day / X / No. days / =
Training materials (eg printing) / =
Catering / Cost per person / X / No. people / =
Participant travel – airfares / Average cost per person / X / No. people / =
Participant travel – mileage / Average cost per person / X / No. people / =
Participant travel - taxis / Average cost per person / X / No. people / =
Participant accommodation
Number of nights / Average cost per person / X / No. people / =
Meals (dinner, breakfast) / Average cost per person / X / No. people / =
Accessibility costs –Training resources (eg NZSL, easy read documents – please itemise) / =
Accessibility costs – Support person (include travel, accommodation, meals) / =
Other (please describe) / =
Total cost of the learning activity including GST (add all totals above) / =
Are you applying for the total cost? / Yes/ No
If no, how much are you applying for? / =
If no, please explain how you will fund the difference, eg other grants, scholarships, internal funding, etc.
*If you plan to use a facilitator who is an employee of the applying organisation/s their facilitation costs can only be claimed if the facilitator will receive additional remuneration for providing facilitation services. This grant must not be used to fund course development or administration costs.
Particpant details

Please complete all sections of the accompanying Microsoft Excel ‘details of participants’ spreadsheet and send it with this application. This information can only be accepted in the excel format provided.

Once the learning activity is completed you will be required to confirm all the named participants completed within the proposed timeframe and provide details of any changes (replacements or additions).

Declaration

The person with delegated authority to enter into a contract with Te Pou must complete this declaration. The application and participant spreadsheet must then be sent to Te Pou from the email address of the authorised signatory.You do not need to physically sign the form; your email and the application will be confirmation of the declaration below.

I state that:

  • I have read the terms and conditionsand fully agree to participate as outlined
  • I have reviewed the information provided by my organisation in this application
  • neither I nor this organisation has any conflict of interest relating to this application
  • I understand that members of a panel will evaluate this application and that any information I supply will be seen by panel members and may be seen by representatives of the Ministry of Health.

And to the best of my knowledge:

  • the content of this application is factually correct
  • no information material to this application has been omitted
  • my organisation has not exceeded the yearly maximum of $80,000 for this grant
  • none of the participants named in this application have exceeded their individual yearly maximum of $5,000.00 (excluding accessibility costs).

NAME of authorised contract signatory:
DATE:
ROLE of authorised contract signatory:

Privacy:

Information relating to an applicant that Te Pou collects from either that applicant or otherwise (including without limitation the application form) (the “Information”) will be stored by Te Pou in accordance with statutory and other requirements and may be accessed by that applicant in accordance with the Privacy Act 1993.Applicants may request corrections to their Information and Te Pou shall respond to such requests in accordance with the Privacy Act. The Information will be used to process applications and to enable Te Pou to report to government and other entities in the health sector, including (without limitation) the Ministry of Health.

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Consumer Leadership Development Grant: 2016