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CSL Grants 2010-2011 HEALTH & WELLBEING of 17

Community Support Levy Charitable Organisations Combined Grants 2010-2011 Application Form

Category BHEALTH & WELLBEING GRANTS

(up to $100,000)

Disability and Community Services

PLEASE NOTE:This grants round has changed significantly since the previous round. Please read the Guidelines carefully, along with the ‘Frequently Asked Questions’ to decide whether your organisation is eligible for these grants and that the proposed project is in line with our objectives.

Please be aware that funding from the Community Support Levy is NOT to duplicate funding from other sources.

Please note that the total amount your organisation can request should be inclusive of GST and be no more than $100,000.


How to complete this Application FormPlease read the Charitable Organisations Combined Grants 2010-2011 Guidelines before completing this application.

Funding under the Community Support Levy Charitable Organisations Combined Grants 2010-2011is available in three categories: category A are Small Grants for funding up to $3000 (for projects up to 12 months in duration); category B are Health & Wellbeing Grants for funding up to $100,000 (for projects up to three years in duration); and category C are ‘Third Place’ Grants for funding up to $500,000 (for projects up to five years in duration).

This Application Form is for category B (Health & Wellbeing Grants) only.

To apply for funding you must: Complete all sections of this document; Sign the Applications Authorisations section – this must be signed by two people; Provide a copy of your Certificate of Incorporation (or that of your sponsoring organisation)

and optional supporting documents if applicable; If your organisation is sponsored, complete Attachment 1; and Send your Application Form to the Gambling Support Program before the closing deadline.

The Guidelines for the Combined Grants 2010-2011 program will assist you in knowing if you are eligible to apply for funding under one or both categories. Please read the guidelines before you apply!

For more information, visit the website at www.dhhs.tas.gov.au/gambling, email [email protected]

or call (03) 6233 3204.


mailto:[email protected]

http://www.dhhs.tas.gov.au/gambling

Applicant DetailsName of the organisation applying for funding and who will deliver the projectEligible organisations are charities or not-for-profit community organisations whose dominant purpose is charitable, altruistic and for the Tasmanian public benefit. These are referred to as charitable organisations throughout the Guidelines and Application Form. Legal status of organisation applying for funding and who will deliver the projectThe applicant organisation must be an incorporated not-for-profit organisation whose dominant purpose is charitable. It will be responsible for running the project and for appropriate acquittal of the funds. If an applicant organisation is not incorporated then it must seek sponsorship from an ‘incorporated charitable entity’. See sponsorship section. Contact details of the person in the organisation applying for fundingFirst name: Phone:

Surname: Email:

Street / PO Box: Fax:

Town:

State: Postcode: Applicant organisation’s Australian Business NumberABN: GST Registration statusIs the applicant organisation registered for GST?

Yes No

Sponsoring Organisation Details (Only complete this if you are not incorporated and you are applying through an incorporated sponsoring organisation)Name of Sponsoring OrganisationIf the applicant organisation (above) is not incorporated then it must seek sponsorship from an ‘incorporated charitable entity’. The Sponsoring Organisation receives the Community Support Levy grant funds and will accept the legal and financial obligations involved in accepting the grant including the transfer of funds to the grantee. The sponsor must complete the attached sponsorship letter. Legal status of organisation applying for funding and who will deliver the projectIs your organisation incorporated? Include a copy of the incorporation certificate with your application. Contact details of the Sponsoring OrganisationFirst name: Phone:

Surname: Email:

Street / PO Box: Fax:

Town:

State: Postcode:

sponsoring organisation’s Australian Business NumberABN: GST Registration status


Is the Sponsoring Organisation registered for GST? Yes No

Project DetailsAbout the ProjectProject titleApplicants submitting more than one application must provide distinct titles for each project . Funding RequestNOTE: The total amount requested including GST will be no more than $100,000$ TotalProject duration in monthsThis grant program has a maximum timeframe of three years (36 months). monthsProvide a brief description of the project (maximum of 100 words)This description provides the assessment panel with a useful working definition. It needs to be concise and descriptive and should include: the target group; a summary of the aims; expected outcomes of the project.

Who is the Target Group?Target Group The target group represents the people in the community for whom your project or request for funding will provide support.

Tick a box that will best describe the type of people you will be supporting. Please try to choose just one group. A second box can be ticked if necessary.

Aged Children Culturally and linguistically diverse groups Families Isolated rural communities Men People with chronic illness People with disabilities People with mental health problems Socio-economically disadvantaged Women Youth Other, please specify _______________________


Delivery of Project to Target GroupWhere is your target audience located? (tick one box only)

The location refers to the site or region where the majority of your target audience is based. This does not refer to where your office is situated.

Statewide Region LGA

Statewide

North

Break O'Day Dorset Flinders George Town Launceston Meander Valley Northern Midlands West Tamar

North West

Burnie Central Coast Circular Head Devonport Kentish King Island Latrobe Waratah/Wynyard West Coast

South East

Brighton Central Highlands Clarence Derwent Valley Glamorgan/Spring

Bay Sorell Southern Midlands Tasman

South West Glenorchy Hobart Huon Valley Kingborough


Details about your organisation’s valuesBriefly outline: the organisation’s mission; and the organisation’s objectives. (limit 250 words)

Details about the Structure of your OrganisationDescribe: the year that your organisation was established; its membership; and organisational structure and/or staffing. (limit 250 words)

More Details About the ProjectDetailed description of your project (500 words or less)

This is an opportunity for you to supply further details about your project or activity.

This may include a review of: other relevant projects, studies and/or literature; the rationale for the project; a concise list of the project’s objectives; expected outcomes.

Other Grant Funding DetailsPrevious Funding for this ProjectHas this project been run at any time in the past? Yes NoIf Yes: When did it run?

How long did it run for? Who funded it? Provide a brief description of outcomes of the last time this project ran. (maximum of 50 words) Details and status of any other Community Support Levy grant funding that your organisation has received (for any project)Year Amount Project title and purpose Current Status

Details and status of any other non-recurrent grant funding, for non-core business that your organisation has applied for from other sources and is awaiting an outcome.Funding body Amoun

tProject title and purpose Current Status


About the Target GroupTarget Group Brief description (limit 250 words)

This is an opportunity for you to supply further details about your target group.

Projects must target vulnerable and disadvantaged groups or communities; these groups are referred to as the target group for the purpose of the Guidelines and Application Form.

The target group may include, but is not limited to areas of: those at risk from trauma; disability; mental health issues; chronic illness; socially, economically or culturally disadvantaged groups and communities.

Consider including information such as the number of people, their age ranges, where they are located, why they should be targeted etc.

About the Target Group (continued)How have the needs of the target population been identified? (limit 250 words)

Provide appropriate evidence.

This could include, but is not limited to: statistical data; the findings and recommendations of reports; surveys; letters of support from the target population; a needs analysis. How will the target group become involved as a key stakeholder or in the decision making process?(limit 250 words)

Involving the target population increases the project’s effectiveness and sustainability.

Examples of ways to involve the target population can include: community meetings or gatherings; social gatherings or discussion groups; face to face contact; steering committees; consultation or focus groups; coaching or mentoring; publicity and marketing.

Project Reach and LocationWhat is the reach of the project or activity? (limit 250 words)

This is an opportunity for you to supply further information about where the project is taking place and how many people your activity will benefit.

This may include, but is not limited to: approximate number of people; specified area/s, town/s, region, etc. over which the project will extend.

Evaluating the success of the project or activity


Progress EvaluationHow will you determine whether the strategies of the project or activity are progressing satisfactorily?Consider: How can you measure stakeholders or partners’ commitment? Are the participants moving towards the anticipated goals of the project? How can this be measured? Which of the activities and strategies are aiding the participants to move toward the goals? Key milestones. Will you achieve them on time? Are activities running according to the workplan? Do you have a risk management plan to support your strategies?

Impact EvaluationHow will you measure the immediate impact of the project or activity, including the changes and effects on the target group and how will these changes relate to the objectives?Consider: The information you need and how you will obtain it and present it.Examples of the types of data that may be collected are: diaries or anecdotal accounts; checklists or inventories; rating scales; questionnaires; interviews; written responses to requests for information, such as letters; products from participants or samples of work.Examples of the way data may be collected include: self-reports; independent observers; audio tape or video tape.

Impact EvaluationSummary Evaluation

How will you evaluate the overall effectiveness of the project?Consider: Were the appropriate participants selected and involved in the planning activities? Did the activities match those described in the plan? If not, are the changes in activities justified and described? Were the materials, equipment and other resources appropriate? Were the activities conducted according to the proposed work plan and timelines? Did appropriate personnel conduct the activities? Were appropriate strategies developed and incorporated to promote participant feedback and how successful were these?

Publicity and MarketingPromoting your ProjectWhat strategies are planned to launch, publicise or promote the project or activity, and to involve the target population?Consider: formal launches by the Minister of Health and Human Services; advertising, including how the project will be marketed to the target population; dissemination of information strategies such as reports, events or newsletters.


SustainabilityPlanning for the FutureLong term benefits

How will the outcomes of this project continue to benefit the target population in the longer term?Consider: How will the project outcomes be made accessible in the future to the:o target group?o broader community? Is there a need to support the target group if the project were to stop:o immediately?o gradually?o continue into the future? What could be put in place to support this need?

Plans to sustain this project

What strategies are planned, if any, to allow this project to continue into the future?

Consider: Can this project be continued under a trained volunteer? Can an outcome of the project be used to recover costs? Can the project be marketed to gain future support? Is there an appropriate sponsor for the continuation of the project? Is there the possibility of working in partnership with another organisation to share resources?

Project Work PlanList the key activities of the project and how long each activity may take to complete (add extra rows if needed).A work plan is developed by defining the project’s key activities and how long they will take. A key activity is an action or event that needs to occur in order for the project to progress. These are sometimes referred to as milestones. For example, key activities for employing a project officer may include advertising in local papers, interviewing applicants, and finalising an employment contract.

Key activities Estimated time


Budget (essential) *Please note that you may use your own template for the budget. Please be as detailed as you can.Operational BudgetSalaries and Wages – direct costs Salaries and Wages – on costs Service Delivery Expenses (eg travel, motor vehicle costs, leasing etc) Administrative expenses (eg book-keeping) Insurances Minor equipment Corporate overheads Depreciation Other Total Budget (incl GST) Salaries and Wages – direct costs and on costs (details of FTE nos and salary rates/awards should also be provided)Team Leader Staff Other Total Service Delivery expensesStaff support (mobile, memberships, subscriptions, meetings etc) Staff training Advertising – general & recruitment Motor vehicles Petrol/car hire Travel & accommodation Other Total Administrative expensesOffice consumables Telephones, computer lines, photocopiers etc Other Total Minor equipment purchases Minor purchases Total Corporate OverheadsBusiness services – accounting, audit, payroll, accounts payable HR – recruitment, awards, personnel management Publicity & promotion Total MarketingPublicity & promotions Public relations Web maintenance, collateral design & management Information system – support, helpdesk, systems maintenance & upgrades Consulting fees Other Total Miscellaneous


Total


Application authorisations (ESSENTIAL)We acknowledge that submitting an application for funding electronically warrants that we are duly authorised to submit an application on behalf of the organisation that is seeking a grant from the Combined Grants 2010-2011. Further, we acknowledge that the absence of a handwritten signature in the application for funding does not invalidate the electronic submission. We also undertake to sign and forward a hard copy of this signature page, along with supporting documentation, where the application was lodged electronically.

Declaration and signature of two persons authorised to sign on behalf of the organisation.

We declare that the information we have given on this form is complete and correct and that the organisation that we represent supports the project.

Signature (SIGN BY HAND)

Print name Position in organisation Phone Date

Signature (SIGN BY HAND)


Declaration and signature of person authorised to sign on behalf of the Sponsoring Organisation (if applicable). Sponsoring organisations must also complete the attached ‘Letter of Agreement to Sponsor’.Sponsoring Organisation Signature (SIGN BY HAND)



Supporting documentsEssential Supporting DocumentsIf your organisation is incorporated you must include a copy of your organisation’s incorporation status.

If your organisation is not incorporated and your application is being sponsored by another not-for-profit organisation, you must include:

a copy of that organisation’s incorporation status; and a completed letter of agreement to sponsor (you may use the Proforma

below).

Optional Supporting DocumentsYou may choose to send letters that will corroborate the value of your project or the role of your organisation.

Submitting your applicationReturn by e-mail to [email protected]. Please e-mail the application as an attachment. A confirmation of receipt of

application will be forwarded by reply e-mail.2. Post the signature page and any supporting documents (see checklist

below).

Return by post or delivery:Please post the application and supporting documents, to:

Gambling Support Program Department of Health & Human ServicesGPO Box 125Hobart TAS 7001

Applications must be received by 5.00pm Thursday 31 March 2011. Late applications will not be accepted.

Applications and supporting documents can be hand delivered to:

Gambling Support Program Department of Health & Human ServicesLevel 3, 99 Bathurst StHobart, TAS 7000

A confirmation email/letter of receipt of application will be forwarded in due course.


mailto:[email protected]

CHECKLIST FOR CONTENT

Is your organisation a charitable or not-for-profit community organisation whose dominant purpose is charitable, altruistic and for the public benefit?

Is your organisation incorporated, or, in the case of unincorporated organisations, do you have a sponsoring arrangement with an incorporated charitable organisation?

Have you filled in EVERY field? Does your project target vulnerable and disadvantaged groups or

communities and have you consulted them? Does your project target those who are at risk of issues with electronic

gaming machine (EGM) gambling? Does your project clearly outline how it meets the aims and objectives of

the funding category for which you are applying? Are you using the official form to apply for the grant? Is your organisation clear about the project, and what the funding is for,

and is your project size realistic? Is the information in your application clear and concise and aimed at an

audience who may know little to nothing about the topic? Have you considered all the risks involved in managing the project? Do you have the required supporting documents? Did you keep proof that the application was faxed, mailed or emailed

before the closing date and did you keep a copy of your application for your own records?

Is the information in your application clear and concise and aimed at an audience who may know little to nothing about the topic?


ATTACHMENT 1For the purpose of the Charitable Organisations Grants Program, an eligible sponsoring organisation is defined as an organisation that is a not-for-profit ‘incorporated entity’ and its dominant purpose is charitable. The Sponsoring Organisation receives the Community Support Levy funds and will accept the legal and financial obligations involved in accepting the grant including the transfer of funds to the grantee. The Sponsoring Organisation must sign the letter below and sign the application authorisation page.

This letter must be provided on the Sponsoring Organisation’s official letterhead

Sponsoring Organisation’s ‘Letter of Agreement to Sponsor’ - EXAMPLE

Date

ChairAdvisory GroupCharitable Organisations Grants ProgramGambling Support ProgramGPO Box 125Hobart TAS 7001

Dear

Our organisation is an incorporated charitable organisation and is prepared to act as the sponsoring body for the [name of applying organisation] should it be successful in obtaining funding from the Community Support Levy Combined Grants 2010-2011, to undertake [name of proposed project].

We are aware that the grant will be paid to our organisation and we accept the legal and financial obligations involved in accepting the grant.

Yours sincerely

[Name][Position in organisation]
