Section 1 - About Your Organisation

Birchwood Grassroots Grants Grant Application Form

1.1 Name of your organisation

1.2 Full address of organisation (including postcode)

Postcode:

1.3 Address of meeting venue (if applicable, including postcode)

Postcode : 1.4 Contact Details

Main Contact Second Contact Title Name Position Tel Mobile Email Section 1 : Continued …

1.5 Please state when your organisation was established and describe the main activities of your organisation (not the project for which you are applying) 1.6 Does your organisation have Yes No a set of rules/terms of reference or constitution?

1.7 Are you? (Please tick all that apply)

A registered charity? Yes No

Other (please state)

Charity Number : 1.8 How many people are involved in your organisation? Full-time paid staff/workers Total number of P/T employees, not Full time equivalent Management Committee

Volunteers

Beneficiaries (people to whom you provide a service)

1.9 Do you have any of the following policies? Child Yes No protection Vulnerable Adults Yes No protection Health & Yes No Safety Equality and Yes No Diversity Complaints Yes No Procedure

Section 2: Your request for funding

2.1 Please give us a brief description of the project you want us to fund

2.2 How do you know there is a need for your project and why is this important to your community?

2.3 How will you know if you have achieved what you set out to do? 2.3 Describe how you will assess the benefit of the work you do

Section 2 : Continued … 2.4 Please give us the projected timescale of your project (MM/YY)

Start Finish

2.5 Which area will you be working in? Section 3: Equality and Diversity

3.1 Who may be the beneficiaries of your project. (Please tick as many boxes as apply)

The whole community People in rural areas People living in urban Early Years areas Children Men Young people Women Adults People with disabilities Older people

3.2 Please tell us which ethnic groups may be the beneficiaries of your project. (please tick as many boxes as apply)

The whole community Asian/British Indian British White Asian/British Pakistani Other White Asian/British Bangladeshi Mixed, Black and White Black/British Caribbean Caribbean Mixed, Black and White Black/British African African Mixed, Asian and White Chinese Asian/Asian British Other European Mixed Other Other

3.3 Approximately how many people will benefit from this grant?

3.4 Is this money for new work, or to continue funding existing work? (Please tick the relevant box)

For new work For existing work Section 4: Your Organisation’s Finances

4.1 Do you have a bank account in the organisation’s name?

Yes No

If Yes please give details: Account Name: Bank / Building Society: Bank / Building Society address:

Sort Code: Account No

If NO, please explain how you will manage the grant payment Cheques cannot be made payable to an individual Section 5: Declaration We agree to abide by the terms and conditions of the grant as they are set out in this application form and in the accompanying guidance, and understand that any offer of a grant will be subject to our proposed work remaining within grant criteria. We agree to participate in monitoring, auditing and evaluation related to this fund.

Our signatures confirm our acceptance of these conditions.

Signatures of applicants

Organisation Chair or Secretary Signature please sign Name please print or type Date

Committee member Signature please sign Name please print or type Total cost of your project £ Date Amount raised so far £

Amount to be raised from other sources £ Warrington Voluntary Amount requested from Grassroots £ Action is registered to hold data under the Data Protection Act 1998

The Freedom of Information Act 2000 The Freedom of Information Act gives members of the public the right to request any information that we hold. Where can third parties get information about your project/organisation? (For example, your website)

Checklist, please make sure that you send all the information necessary to support your application:

Essential items : This signed and completed application form Your organisation’s set of rules/terms of Whatreference/constitution happens next? Your latest set of accounts 1. Please ensure that you have completed all sections of the application form, and have Itemsattached you mayany additionalneed to send, papers dependent (see the above on your checklist) application: Any additional papers you used 2. Please return this form (signed) to: Warrington Voluntary Action, The Gateway, 89 Sankey Street, Warrington, WA1 1SR.

3. Your application will be processed by Warrington Voluntary Action for completeness and eligibility. If you fail either component your application will not be forwarded to the Assessment Panel for consideration.

4. The Assessment Panel sits every 2 months. The closing date for each Panel meeting will be at 17.00 on the last day of the previous month. Once the Panel has sat Warrington Voluntary Action will inform you in writing of the panels’ decision normally within 5 working days.

5. There is no right of appeal; applicants can make a fresh application based upon consideration of feedback given, subject to eligibility criteria being adhered to.

6. Successful applicants on return of acceptance letter to Warrington Voluntary Action will receive payment normally within 10 working days.

7. The Assessment Panel reserves the right to suspend determination of future applications if non-compliance issues on previous applications are outstanding.