Wellbeing Grant Application Form

Instructions: To apply for a Wellbeing Grant, please complete this application form and email the completed form to [email protected] Please refer to Wellbeing Grant Procedure JEM PR 0038 for more information.

Section 1: Applicant Information Name Position Title Employee Number Functional Unit Department

Section 2: Eligibility Criteria Does the initiative have a strong focus on employee Yes No (circle the correct answer) health and wellbeing? Is the initiative for a group of employees? Yes No (circle the correct answer) Can the applicant provide photos and a brief story Yes No (circle the correct answer) about the initiative which may be shared internally? What health and wellbeing risk will the proposed initiative address? How much (if any) financial contribution will employees provide towards the initiative? How much financial contribution will Jemena be requested to provide towards the initiative? Does the initiative support a charity? If so, state name of charity and how charity is supported

Section 3: Information about the Proposed Health and Wellbeing Initiative Name of Proposed Initiative

Specific Details

Expected Outcome

Names of Participants (or expected number of participants)

Date of Proposed Initiative

of 2 JEM PR 0038 FM 01, Rev: 1 Next Review Due: 31/05/2018 How will you invite employees to participate? How will you communicate with participants? What information will you communicate and how often?

Funds requested (please comment if this is an estimate)

Description of how the requested funds will be used

Please provide any additional comments

Section 4: Terms and Conditions

1. The ‘applicant’ specified in the Applicant Information section of this form accepts responsibility for coordination and delivery of the health and wellbeing initiative, should a Wellbeing Grant be approved. 2. All applications must meet the eligibility criteria, outlined in the Wellbeing Grant Procedure. 3. Where financial co-contribution is required from employees, it is the responsibility of the ‘applicant’ to coordinate the collection of money from participating employees.

By signing this application form, you indicate that you have read and accepted the Terms and Conditions

Applicant Name: Applicant Signature: Date:

Manager, please sign below to indicate that you are aware this Wellbeing Grant is being submitted. Applicant’s 2-Up Manager:

2-Up Manager Name: 2-Up Manager Signature: Date:

of 2 JEM PR 0038 FM 01, Rev: 1 Next Review Due: 31/05/2018