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Club Grants

CATEGORY 1 - APPLICATION FORM 2017

All fields are MANDATORY unless stated
Name of Organisation Applying for Funding:
Council Area:
   

Primary Contact Details:

Title:
Name:
Postal Address:
Suburb:
State:
Postcode:
Phone:
FAX:
Email:
   

Secondary Contact Person Details:

Title:
Name:
Phone:
FAX:
Email:
 

Banking Details: (optional)

Account Name:
Account Number:
BSB:
 
Project Name:

If your application for funding is successful you will be required to:

  • make an appropriate level of acknowledgement of the funding source for the project;

  • complete an evaluation form at the end of the project.

  1. Has your organisation submitted a report / progress form to the Club Grants Local Committee convenor and/or club for previous funding?
Yes No
  1. What category of funding are you applying for?
    (If you select Category 2 you will be taken to the Category 2 form)
  1. Has your organisation received Club Grants funding from Rooty Hill RSL before?
Yes No
  1. Please provide a short outline of your project (what you are going to do or provide, e.g. details of your event, service, product etc)
  1. From the list below, which category best describes your project? (Please tick ONE box only)
A1 - Family Support/Emergency or Low Cost Accommodation
A2 - Child Protection/Child Care
A3 - Counselling Services
A4 - Aged, Disability or Youth Services
A5 - Victims of Natural Disasters
A6 - Volunteer Emergency Services
A7 - Veteran Welfare
B1 - Neighbourhood Centre/Youth Drop in Activities
B2 - Community Transport Services
B3 - Community Education Programs
B4 - Tenants Services
B5 - Statewide or Regional Services Developing Social Policies & Providing Advocacy for Local Communities
C1 - Early Childhood Health/Child and Family Services
C2 - Community Nursing/Therapy/Mental Health Services
C3 - Drug & Alcohol/Palliative Care/Women's Health/Aboriginal Health/Dental Services
C4 - Home and Community Care & Disability Services
C5 - Health Promotion Initiatives
D1 - Employment Placement/Advocacy Services
D2 - Group Training Companies
D3 - Community Enterprises
D4 - Local Job Creation Scheme
  1. How will you manage, monitor and deliver this project? (How will you ensure it achieves its aims?)
  1. If you expect indirect beneficiaries, who might they be?
  1. What impact do you hope to have on your identified local community priority needs?
  1. Does the project need to be followed up after completion? If yes, how?
  1. Has your application been supported by any other community organisations or do you intend to work in partnership with any other organisation on this project?
Yes No
Commencement Date:
Completion Date:
  1. What is the proposed commencement date and completion date for the project?
  1. Is the expenditure on community development and support to be applied outside Blacktown LGA?
Yes No
  1. Is this program, project or service already assisted by an existing local, State, or Commonwealth Government funding program? If so, please give details (if different to q10)
Yes No
  1. Have you applied, or do you intend to apply, to any other registered club or any other funding body for this project ?
Yes No
  1. What is the total amount of Club Grants funding you are seeking for this application?
  1. Will your project still be viable if you receive Club Grants funding less than the requested amount?
Yes No
  1. Please outline below the project budget for your proposal, including funding from this source (Community Development & Support Expenditure) and any other funding sources.

Budget Item

Club Grants

Other funding sources

Salaries $ $
Fees $ $
Administration $ $
Program costs (including telephone, stationery, postage, audit, promotion) $ $
• Capital equipment $ $
• Rent $ $
• Other $ $
Total funds $ $

 

  1. Please attach a copy of your last annual report including financial statements and auditor’s report. Have you attached the report?

Yes No

Attachment Annual Report:

(FileType: pdf,doc,docx, or zip Max File size: 5MB)

Attachment Auditor's Report:

(FileType: pdf,doc,docx, or zip Max File size: 5MB)

  1. Please state your ABN/GST status: (optional)
ABN

GST Status
  1. Is your organisation a non-profit organisation?
Yes No
  1. Is your organisation incorporated?

Yes No

  1. Image Verification:
    Please type the image text