Appendix 1 - Application Form

COMMUNITY GRANTS PROGRAM (Round 1) 2010 / 2011 APPLICATION FORM

Before filling in your application form, please read all the information contained in the Information Kit. This application form must be completed in full and all relevant documents must be submitted in order for your grant application to be considered.

APPENDIX 1 - APPLICATION FORM

Note: Application forms can be downloaded from the Glenelg Shire Council webpage: www.glenelg.vic.gov.au

1.1 Which category do you wish to apply for?  Tick one of the following: Recreation Public Halls Tourism Arts, Culture and Heritage Community Plan Support Community Support

1.2 Is this is a request for a Triennial Grant Yes No If yes, you must discuss your application with relevant council officer If yes, please fill out template on page 19

Community Grants Program (Round 1) 2010/2011 Application Form (Amended 13 July 2010) 1 APPENDIX 1 - APPLICATION FORM (continued)

PART A: APPLICANT DETAILS (Compulsory to complete this section) 1. Name of your organization / group:

2. Address of your organization / group: Street: City: Post Code:

3. Postal Address (if different from above): Street: City: Post Code:

4. Contact person for application: Note: This should be a person who has knowledge and a copy of the application. Name: Position: Phone: A/H: Mobile: Fax : Email :

5. Is your organization / group incorporated?

YES NO

If YES, please provide your Incorporation Registration Number below and then go the Question 7.

If NO, and if applying for more than $500 please provide the following auspice organization details. If you are applying for less than $500 go to Question 7.

PART A: APPLICANT DETAILS (Compulsory to complete this section) (continued)

6. Auspice organization details: Name of auspice organisation: Address of auspice organisation: Street: City: Post Code:

7. Is your organization / group or auspice organization registered for GST? Please tick:

YES NO

If YES, provide your organization / group or auspice’s ABN.

8. Does your organization / group have Public Liability Insurance? Please tick

YES NO

If YES, Company Insured with:

Policy Number:

Amount covered: $

Certificate of Currency (please attach a copy)

9. Bank Account Name of organisation / group for cheque to be made out to (Cash grant applicants only)

BSB: Account number: Account name: Fax number: Email address:

PART A: APPLICANT DETAILS (Compulsory to complete this section) (continued)

9. What year was your organization / group established?

10. Please provide a brief history / description of your organization / group (50 words or less)

PART B: ABOUT YOUR PROJECT (Compulsory to complete this section)

Note: A project can be taken to mean equipment, event or program

1. Name of proposed project or activity:

2. Description of Project/Activity:

3. Project start date:

4. Project completion date:

5. Address or venue where the project or activity will be carried out:

6. Is this a new project or activity? Please tick

YES NO

PART B: ABOUT YOUR PROJECT (Compulsory to complete this section) (continued)

7. Is this project or activity being undertaken in partnership with another organization / group? Please tick

YES NO

If YES, please provide the name/s of the group/organization below and attach evidence of the partnership from the partner agency (i.e. letter).

8. What is the level of risk of accident or personal injury to participants in projects or activities? (Only relevant for projects involving events or activities)

HIGH MEDIUM LOW

Please complete Risk Management template attached (Appendix 2, pg 16).

9. How many people do you estimate will participate in your project or activity. Note: Participation is defined broadly and includes paid workers, volunteers and patrons.

PART C: FINANCIAL INFORMATION (Compulsory to complete this section)

1. Has your organization / group previously received a grant from Glenelg Shire Council in the last 3 years? If more than one grant in this time period, please provide additional details on a separate page.

YES NO

If YES, please detail below:

Purpose:

Amount: $

2. Is your organisation or group currently receiving any other support from Glenelg Shire Council (e.g.) funding or in-kind.

Please tick:

YES NO

If YES, please detail below:

Purpose:

Amount: $

3. Is this the only source of funding for your project?

YES NO

PART D: PROJECT BUDGET (Compulsory to complete this section)

INCOME $ EXPENDITURE $

Cash amount sought from Council’s Community Grants $ Administration overheads $ Program

Venue Hire Subsidy: (Enter quote total from Part G of $ Advertising and Promotion $ application form)

Other Government $ Contingencies and $ Allowances

Other Association $ Education and Training $

Funds from your $ Labour and Materials $ organization

Community fundraising $ Printing $

In-kind support (volunteer $ Salaries (please detail) $ time, etc)

Business contribution $ Transport $

Philanthropic contribution $ Venue / Meeting room hire $

Other (please specify) $ Other including In-kind $ (please specify)

Total Income $ Total Expenditure $

Note: Expenditure should equal income

Total amount sought from Glenelg Shire Council for project/activity:

Cash Grant $ In-Kind Support (if applicable) $ (maximum $500)

TOTAL $

Note: The total budget for combined cash grant and venue hire subsidy applications must not exceed the maximum amount of $5,000.

PART E: PROJECT DETAILS (Compulsory to complete this section)

Note: A project can be taken to mean equipment, event or program

Please answer the following questions about your project. Refer to the application guidelines, in particular the assessment criteria information to help you answer the questions. Responses should be no more than 50 words. Attach additional pages if required.

1. How will residents living in the Glenelg Shire benefit from your program or activity. If there are particular groups or communities that will benefit please include them in your answer (50 words or less).

2. What will the project achieve? (50 words or less)

3. Why is this project needed? (50 words or less)

4. How will the project be carried out? (50 words or less)

PART F: PROJECT PLAN (Only applicants for large 3 year recurrent grants)

Applicants for recurrent 3 year grants must possess the following:  A history of effective service delivery and support or ability to demonstrate ongoing capacity to the Glenelg Shire community.  A focus on service delivery to disadvantaged residents, major issues of community concern or iconic festivals and events.  Clearly documented service delivery priorities and expected outcomes.  Sound governance and management structures and financial status.

1. Please attach a copy of your organizational Annual Report or Business Plan.

2. Please provide a Project Plan for your proposal as below, using the template on page 18. YEAR ONE: Objective/s: .. ………………………………………………………………………………………… Strategies/Actions (include timelines and completion dates): ……………………………. …………………………………………………………………………………………………………… Expected outcomes/s: ……………………………………………………………………………..

YEAR TWO: Objective/s: .. ………………………………………………………………………………………… Strategies/Actions (include timelines and completion dates): ……………………………. …………………………………………………………………………………………………………… Expected outcomes/s: ……………………………………………………………………………..

YEAR THREE: Objective/s: .. ………………………………………………………………………………………… Strategies/Actions (include timelines and completion dates): ……………………………. …………………………………………………………………………………………………………… Expected outcomes/s: ……………………………………………………………………………..

3. How will you know if your project or activity is successful? Please outline how you will evaluate your project or activity below. For help with this question contact the relevant Council Officer (refer page 15 of the Information Kit)

PART G: DECLARATION / APPLICATION CHECKLIST (Compulsory to complete this section)

DECLARATION

I certify that all details supplied in this application form and in any attached documents are true and correct to the best of my knowledge, and that the application has been submitted with the full knowledge and agreement of the management of the applicant organization/group. I have read the Community Grants Program (Round 1) 2010 / 2011 Information Kit and have discussed my application with the relevant Council Officer where applicable with this application form. The Glenelg Shire Council will be contacted immediately if any information provided in this application changes or is incorrect.

Title: Ms Name: Date: Position in organization / group:

Signature: please ensure that a signature is placed in the box below. All applications must have signatures.

Please complete the Privacy Act Statement of Consent and Checklist on the following pages before submitting this application.

APPLICATION CHECKLIST

Please complete the checklist below and attach it to the front of your application.

Note: Any additional materials provided will not be returned.

Completed Application Form.

Information and supporting documentation that must be provided.

Current Public Liability Certificate, if applying for use of any Council venue and/or cash grant over $2,000.

ABN if your organization is registered for GST.

Financial Statement – most recent.

Privacy Act Statement of Consent.

Relevant promotional brochures or advertising material (optional).

Minutes of Public Meetings (Community Plan Support grant category).

Information and supporting documentation, if applicable:

Certificate of Incorporation, if applying for cash grant over $500.

Auspice organization details, if not incorporated and applying for more than $500.

Annual Report, Business Plan or Minutes of the last AGM Meeting.

Evidence of partnership from partner agencies (if applicable).

APPLICATION CHECKLIST (continued)

Information and supporting documentation, if applicable (continued):

Have you kept a copy of your application and supporting documentation for your records.

Permits.

Quotes.

In-Kind costs (list of labour and/or donated goods and services).

Details of additional grants previously received from Glenelg Shire Council (if applicable).

PART H : INFORMATION PRIVACY ACT STATEMENT OF CONSENT (All applicants to complete)

INFORMATION PRIVACY ACT STATEMENT OF CONSENT

Please note:

As part of the Information Privacy Act Statement of Consent, Council is collecting the information on this form for the purpose of registering and administering your Community Grants Application.

The information may also be used to send you newsletters and information and to ascertain your satisfaction with our services. Please indicate whether you wish for your information to be used for this purpose:

Regular updates and newsletters: YES NO

Satisfaction surveys: YES NO

The information will not be disclosed except as required by law. In particular, the information will not be disclosed to others for marketing purposes.

APPENDIX 2 - RISK MANAGEMENT PLAN TEMPLATE

Community Grants Program (Round 1) 2010/2011 Application Form (Amended 13 July 2010) 14 Community Grants Program (Round 1) 2010/2011 Application Form (Amended 13 July 2010) 15 APPENDIX 2 - RISK MANAGEMENT PLAN TEMPLATE (continued)

RISK ASSESSMENT

Potential Identified Hazard Risk How will risk be controlled By Who By (delete where not applicable) Level When

Community Grants Program (Round 1) 2010/2011 Application Form (Amended 13 July 2010) 16 APPENDIX 2 - RISK MANAGEMENT PLAN TEMPLATE (continued)

Community Grants Program (Round 1) 2010/2011 Application Form (Amended 13 July 2010) 17 PROJECT PLAN (Only applicants for large 3 year recurrent grants)

YEAR ONE:

Objective/s:

Strategies/Actions (include timelines and completion dates):

Expected outcome/s:

YEAR TWO:

Objective/s:

Expected outcome/s:

YEAR THREE:

Objective/s:

Expected outcome/s:

Community Grants Program (Round 1) 2010/2011 Application Form (Amended 13 July 2010) 18 APPENDIX 3 - SPARE COVER PAGE TO BE USED WHEN SUBMITTING ADDITIONAL DOCUMENTATION

The applicant is to REMOVE this page from the Application Form and forward with any FUTURE communication with Council in reference to your Application. This page enables Council to accurately identify any further information that is supplied by the applicant.

1. Name of organisation / group: ……………………………………………………………………………………. ……………………………………………………………………………………..

2. Address of your organization / group: ……………………………………………………………………………………. ……………………………………………………………………………………..

3. Contact person for application: Name: ……………………………………………………………………… Position: ……………………………………………………………………… Phone: ……………………………………………………………………… A/H: ……………………………………………………………………… Mobile: ……………………………………………………………………… Fax: ……………………………………………………………………… Email: ………………………………………………………………………

Tick correct category

 Recreation

 Public Halls

 Tourism

 Arts, Culture and Heritage

 Community Plan Support

 Community Support

Community Grants Program (Round 1) 2010/2011 Application Form (Amended 13 July 2010) 19