ACTIVE BELFAST GRANTAPPLICATION FORM

CLOSING DATE12.00pm Friday 7th March 2014

Office Use Only

Reference Number

Date Received

Time Received

ACTIVE BELFAST

(FUNDING PROVIDED BY THE PUBLIC HEALTH AGENCY AND BELFAST CITY COUNCIL)

THIS FUNDING IS TO SUPPORT PROGRAMMES WITHIN THE BELFAST CITY COUNCIL AREA ONLY

This application has four parts:

PART A: About your organisation and its governance;

PART B: About your project and the costs;

PART C: (Nutrition component Optional) *If your organisation is interested in applying for additional funding of up to £1000 to include a nutritional element within the programme, please fill out PART C of the application;

PART D: Declaration and Referee.

Please firstly read the guidance notes and continually refer to the notes while completing this form.

PART A - ABOUT YOUR ORGANISATION AND ITS GOVERNANCE

Please type or write clearly in black ink.

INFORMATION ABOUT YOUR ORGANISATION

Question 1

Name of your Organisation:

Contact address,including full postcode:

If your organisation is a limited company please provide registered name and full address if different from above:

Name of main contact for your organisation

Mr/Ms/Mrs/Miss/Dr/Other

Address if different from above:

Position held in organisation:

Phone: Daytime: Fax no: E-mail address:

Please tell us if you have any particularcommunication needs:

Question 2 - When was your organisation set up? Year

Question 3 - What type of organisation/group are you?

A Social Enterprise Organisation Unregistered charity, club, society or association, community based group or

organisation Organisation recognised by HM Revenue & Customs (previously known as

Inland Revenue) as charitable for tax purposes Charity Registered with Charity Commission in NI Charity registered in England or Scotland (OSCR) or Wales

Educational Establishment

Registered Charity Number and date of registration:Company Limited by Guarantee Number and date of registration:VAT registration number if applicable

Question 4 - How many people are involved in running your organisation?

Committee and/or Board Volunteers (unpaid)members

Paid staff: Full time Paid staff: Part time

Question 5 - Aims and objectives of the organisation. (Word limit 250)

Question 6 - Organisation financial controls / policies and procedures

6.1 Financial Controls Yes NoA written policy on cash handling arrangementsA written policy on banking arrangements A written policy on purchasing goods and services A written policy on delegated authorityA written policy on how to report and respond to a suspected fraud within the organisation

A written policy on segregation of duties i.e. where no one person can order, receive and pay for goods and services

A written policy on travel and subsistence expensesSystems for regular bank and cash reconciliationA systems for recording income and expenditure transactions

That cheque books and receipts are held in a safe/cash box to which access is strictly controlledNecessary insurance cover for public liability, employer liability, property/contents – where applicableHave all of the above systems been approved by the management committee?

6.2 - Are all of the above regularly reviewed? Yes No

How often are they reviewed e.g. quarterly/annually? ______________

6.3 - If your organisation has a computer do you have IT security procedures e.g., regular backups, password protection?

Yes: No: Not Applicable:

6.4 Policies & Procedures Checklist Yes No

Health and Safety PolicyEqual Opportunities PolicyChild Protection PolicyVulnerable Adults Policy (if applicable)Data Protection PolicyBribery PolicyFreedom of Information Policy (if applicable)

6.5 Additional information which will be required

Governing DocumentAudited/Unaudited Annual AccountsBank statementsCurrent Committee Members/ trustees/ DirectorsOrganisation Chart

PART B: ABOUT YOUR PROJECT AND THE COSTS

Question 7

7.1 Priority Area

Priority 1 Priority 2

please tick one

7.2 Theme Building Capacity

Access to Places

Walking Cycling

please tick one

Question 8

8.1 Project name:

8.2 Project lead officer: (if different from contact details supplied in Part A)

Name

Address

Phone

Email Address

8.3 How much is your organisation applying for from this funding?

£

8.4 Total project cost (if different from above)? £

8.5 Has your organisation secured match funding for this proposal?

Yes No

8.6 Match funding amount £

8.7 Match funding provided by

8.8 Status of application

Question 9 - Dates for the project

9.1 Expected start and end date of project

Start date:

End date:

9.2 Duration of project

Question 10 - Project location and geographical coverage

10.1 Delivery of Project

Please tick10.2 Participants recruited from

Please tick

City Wide City Wide

Balmoral Balmoral

Castle Castle

Court Court

Laganbank Laganbank

Lower Falls Lower Falls

Oldpark Oldpark

Pottinger Pottinger

Upper Falls Upper Falls

Victoria Victoria

10.3 - Which setting(s) will the project take place in?

Question 11 - About this project

11.1 Describe your project? (Word limit 400)

11.2 Please state the overall aim of your project? (Word limit 75)

11.3 Please state the objectives of your project? (Word limit 150)

11.4 - Partnership involvement, what is their role/responsibility?

Partner Organisation Contact Details What is their role/responsibility

12 Who will benefit from your project? Please tick

12.1 What ages are the people your project is aimed at?

Under 5’s

5 – 11

12 - 18

19 - 30

31 – 49

50 - 64

65+

12.2 What gender are the people who will be taking part?

Male Female

Yes No Yes No

12.3 Is your project targeting inactive people?

Yes No

12.4 Is your project targeting people with disabilities?

Yes No

12.5 Is your project targeting people from those groups under section 75

Yes No

12.6 How many direct participants do you expect to benefit?

12.7 What will be the method of recruitment for participants? (Word limit 75)

Question 13 - Please provide a brief description of what activities your project will include, measurable objectives and annual target along with the outcomes you hope to achieve and how these will be measured?

Brief description of

activity

Measureable objectives

Annual target Outcomes Proposed Method of Measuring Outcome

Question 14 - Addressing local need and beneficiaries’ involvement?

14.1 Provide evidence that your project will address a local need. (Word limit 200)

14.2 How have beneficiaries/service users, been involved in planning the project? (Word limit 150)

Question 15 Have you addressed the sustainability of the project, or developed an exit strategy? (Word limit 150)

Question 16 - Please indicate your experience in the management and delivery of similar projects. (Word limit 150)

Question 17 - What are the risks or uncertainties that are associated with your project/service and how do you propose to manage them? (Word limit 150)

Question 18 - Please tell us with whom and how you intend to share the learning from this project with to influence policy and practice? (Word limit 150)

Question 19 - Has your organization previously received funding?

Project Title Amount Awarded

Funding Source Status

Question 20 - Breakdown of funding requested

This pro forma will be used to determine the cost effectiveness of your programme. Salary costs per post Rationale for costing1. Job Title £2. Salary £3. Employer’s NIC £4. Employer’s Pension £5. Total Salary Cost (annual) (i.e.

2+3+4)£

6. Hours Worked £

Programme costs (detail) Rationale for costing£££££££

Project running costs & overheads ££££££££

Capital costs (if any – detail) £££££

Other expenditure ££££

Total Expenditure (annual) £

PART C – NUTRITION COMPONET (OPTIONAL)

Question 21

Please only complete this section if you wish to include a nutrition component to your programme.

Nutrition programme outline Key Actions for 2014/15

Time- frame Planned outcomes Cost Delivery agents

PART D – REFEREE AND DECLARATION

REFEREE

Name

Occupation

Contact address, including full postcode

Phone (Daytime) Phone (Evening)

DECLARATION

All the information given is correct and complete.

Please sign below

Signed: Signed:

Print Name: Print Name:

Position: Position:

Date: Date: