SPORT NEW ZEALAND/KIWISPORT RURAL TRAVEL FUND APPLICATION FORM 2016/2017 (Please do not write outside the printed lines)
A Details
Name of Organisation Click here to enter text. Contact Person Click here to enter text. Postal Address Click here to enter text. Physical Address Click here to enter text. Telephone Click here to enter text. Email Click here to enter text.
B Contact Names
Please provide Click here to enter Click here to enter 1 Name text. Telephone text. Click here to enter Click here to enter 2 Name text. Telephone text.
C Organisation Details
1 How many members belong to your Club/Organisation? ______
2 Are you a club or school? ______
3 Will the travel subsidy benefit participants aged between 5 and 19? YES/ NO
(If yes, how many participants?) ______
4 How many participants are aged between 5 and 12 years? ______
5 How many participants are aged between 13 and 19 years? ______
6 What is the total number of male participants? ______
7 What is the total number of female participants? ______
8 Does your application involve a partnership with a local school/club? YES/NO
9 What is this funding going to be used for? (Briefly explain)
Click here to enter text.
10 What percentage of your members live in the vicinity of the local authority you are applying to for the rural travel fund? Click here to enter text.% D Financial Details
1 Are you registered for GST? YES / NO
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(If yes, please write your GST number in the space provided below. Note: if your application is successful and you are GST registered, we will request a GST Tax Invoice before payment is made)
GST Number Click here to enter text.
2 Finance If GST Registered: $Click here to enter text. Your contribution (minimum of 50%) $Click here to enter text. Other funding $Click here to enter text. Sport New Zealand funding $Click here to enter text. Total cost of the project $ Click here to enter text. Total amount applying for GST exclusive $ Click here to enter text. Total amount applying for GST inclusive If NOT GST Registered: $Click here to enter text. Your contribution (minimum of 50%) $Click here to enter text. Other funding $Click here to enter text. Sport New Zealand funding $Click here to enter text. Total cost of the project $Click here to enter text. Total amount applying for
3 Have you applied to any other Organisation for funding and if so what was the result (briefly explain)? Refer to Table 1 below. Table 1
Organisation Amount requested ($) Results date (if known) (including other councils) Click here to enter text. Click here to Click here to enter text. enter text. Click here to enter text. Click here to Click here to enter text. enter text. Click here to enter text. Click here to Click here to enter text. enter text. Click here to enter text. Click here to Click here to enter text. enter text.
4 Do you have endorsement of your local affiliated Club/School for this application for funding? (This is only relevant if the group applying is the regional body).
YES/ NO (briefly explain and attach evidence of this) Click here to enter text. E Travel Information
Total distance travelled (km) Click here to enter text. Total number of trips Click here to enter text. Total number of vehicles used Click here to enter text.
F Declaration
We hereby declare that the information supplied here on behalf of our Organisation is correct. 3
We consent to the Kaipara District Council collecting the personal contact details and information provided in this application, retaining and using these details and disclosing them to Sport New Zealand for the purpose of review of the Rural Travel Fund. This consent is given in accordance with the Privacy Act 1993.
1 Name Click here to enter text. Position in organisation/title Click here to enter text. Signature Date Click here to enter text.
2 Name Click here to enter text. Position in organisation/title Click here to enter text. Click here to Signature Date enter text.
Please attach: 1 A balance sheet from your organisation (i.e. financial statement - 1 page). 2 A deposit slip for your bank account (in case your application is approved). 3 Evidence of your endorsement from your local affiliated club/school (if required). 4 Draws for games and quotes for transport.
Checklist: 1 Have you answered every question? (If you do not answer all of the questions the application will not be considered.) 2 Have you attached the relevant documents with your application?
Send your application form with the relevant documents to:
Paula Guy Stuve Kaipara District Council Email: [email protected] Private Bag 1001 Telephone: 0800 727 059 Dargaville 0340 By 4.30pm Friday 31 March 2017
Late applications will not be accepted
Rural Travel Fund Criteria
The linking of the KiwiSport Fund to the Rural Travel Fund will address an identified barrier to increased numbers and opportunities for children in playing or gaining skills in sport.
Applications to the Fund must show travel funding used: For either more students to access current opportunities or for students who currently participate to access new opportunities;
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For either during school or out-of-school times;
For either primary or secondary school aged students;
In partnership with a school or club.
We are looking for applicants to match money from this Fund i.e. the amount being applied for must not total more than 50% of the total cost of your project (please note you must provide evidence of the other 50%; either letters from other funders confirming funding or bank accounts from you as the applicant proving funding is available.)