Living Healthier Lives Community Grants Program … · Web viewI am aware that if I have an interest that conflicts, or may conflict, with the receival of grant funding: I must disclose

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Living Healthier Lives Community Grants Program Application FormThank you for your interest in the Living Healthier Lives Community Grants program. Before completing this form, please ensure that you:

1. have read and understood all of the information in the Grant Program Applicant Guidelines

2. contact the Project Officer, Transformation Innovation Collaborative to discuss your project proposal and how this will meet the objectives of the program on 07 3156 9815.

Section One – Applicant Details

1.1 Organisation

Legal name of organisation:

Click or tap here to enter text.

Trading name(if applicable):


Postal address: Click or tap here to enter text.

Suburb: Click or tap here to enter text. Postcode: Click or tap here to enter text.

Telephone: Click or tap here to enter text.

Page 1 of 15 – Living Healthier Lives Community Grants Application Form

Grant Reference Number:Date Received: Acknowledged:

mailto:[email protected]

1.2 Entity type

Please tick the box that best describes your organisation:

☐ Incorporated not-for-profit organisation

☐ Not-for-profit company

☐ Not-for-profit trust

1.3 Contact person

Name the contact person responsible for the daily coordination of the project.

Name Click or tap here to enter text.

Position Click or tap here to enter text.

Telephone Click or tap here to enter text.

Mobile Click or tap here to enter text.

Email Click or tap here to enter text.

1.4 Administering organisation

If your organisation is incorporated please skip this question.

If your organisation is not incorporated, the grant must be applied for on your behalf by a not-for-profit incorporated organisation or a local government. The administering organisation will be responsible for accepting and adhering to the conditions of the grant, maintaining financial records and providing acquittal information, should your application be successful.

The administering organisation’s legally authorised officer must sign the declaration in Section Five and the taxation and bank details in Section Six.

Legal name of incorporated administering organisation:


Trading name (if applicable):


Contact person: Click or tap here to enter text.

Postal address: Click or tap here to enter text.


Suburb: Click or tap here to enter text. Postcode: Click or tap here to enter text.

Telephone: Click or tap here to enter text.

Facsimile: Click or tap here to enter text.

Email: Click or tap here to enter text.

1.5 Please provide a brief description of your organisation and its role in the community.



Section Two – Project Details

2.1 Project name: Click or tap here to enter text.

2.2 Funding amount requested: Click or tap here to enter text.

2.3 Please identify the community health outcome or health issue your project is targeting:


2.4 Tick which category best describes what the funding will be used for:

☐ New one-off time limited projects

☐ Top up existing programs/services to build short term capacity

☐ New long-term programs/services. Please describe at 2.14 how your project will be sustained.

☐ Other

If ‘other’ please describe: Click or tap here to enter text.

2.5 Outline the objectives of your project, how they will help to achieve the objectives of the Living Healthier Lives Community Grants program and meet the criteria outlined in the Grant Program Guidelines. Refer to pages 4 and 5 of the Guidelines. Dot points addressing Living Healthier Lives Community Grants program objectives and criteria is acceptable.


2.6 Describe your project and how you are planning to carry it out.Include the activities you will run to reach your aim(s). It is required that applicants include a copy of a project plan as a companion to this application form. A Metro South Health project plan template is available on the Living Healthier Lives Community Grants webpage should you require assistance.Click or tap here to enter text.

2.7 Please provide details on how consumers are involved in both the planning and delivery of your project.

Please note that it is a requirement of the National Safety and Quality Health Service (NSQHS) Standards, Standard 2: Partnering with consumers that consumers are involved in:

health service planning and design


service delivery service monitoring and evaluation.

As a sponsored project of Metro South Health and Brisbane South PHN, successful applicants are expected to adhere to NSQHS Standard 2. Please refer to the NSQHS Standards website for further information: www.nationalstandards.safetyandquality.gov.au/


2.8 Timeline of your project. Please indicate the dates you expect to start and finish your project. You may also wish to include a high-level timeline of proposed activity as a companion to this application.

Please note, the application process and eventual confirmation and funding of successful applicants may take up to 12 weeks. As such, you will need to allow approximately three months’ lead time before you can start the project. Please insert actual estimated dates.

Estimated project start date: Click or tap here to enter text.Estimated project end date: Click or tap here to enter text.

2.9 What region/s will your project run in?

☐ Brisbane south

☐ Bayside/Redlands/Bay Islands

☐ Beaudesert

☐ Logan

2.10 Please identify the target population (demographics and count) that are expected to benefit from the project.


2.11 Community partnerships. What other groups, organisations, local governments or government agencies are involved in planning and implementing your event/activity? Please list ALL the organisations involved, with contact details and how they are contributing.

Organisation name Contact person, Phone How is this organisation involved?

e.g. XYZ Organisation John Smith, xxxx xxxx On planning committee, free venue


http://www.nationalstandards.safetyandquality.gov.au/


Target outcomes Owner Performance

indicatorBaseline

performanceTarget

performanceWho will measure

Completion Date

E.g. List the measurable results that are sought from undertaking the project.

E.g. the organisation/ individual accountable for the expected outcome.

E.g. The measure that will be used to indicate the level of achievement of the outcome(s).

E.g. The current level of the performance indicator.

E.g. The target level of performance

E.g. The organisation / individual responsible for measuring the performance.

E.g. The date by when the target levels are to be achieved

2.12 Please describe how you will show if your project has been successful, including measurable outcomes:


2.13 Please describe what you perceive to be the risks to your company successfully delivering the proposed program?


2.14 Please identify if and how the project will be sustained in the community beyond the grant funding.



Section Three – Project BudgetIt is important to show how you plan to spend the grant and whether you expect any other income to support your project.

Use the table below to prepare a high-level project budget and show where the money for your project is coming from and how it will be spent. Include the Living Healthier Lives Community Grants program funding and specifically outline what areas the grant will be allocated to. If you are receiving funds from other sources to support your project, it is important you show evidence of where the money is coming from.

Do not include GST in your costings.

Note: Please also include your organisation’s cash and ‘in-kind’ contributions.

Budget items (i.e. what the money

will be spent on.

This grant amount

($) (excl. GST)

Other funding amount

($) (excl. GST)

In-kind support -

Please estimate the dollar value of the in-kind support ($)

Source of other funding or in-kind

support - Please state if confirmed or unconfirmed

For example: Catering $500.00 $2000.00 $500 Share of XYZ Confirmed

Total: $ $ $


Section Four – Grant ConditionsThe grant will be provided under the following terms and conditions:

Note for the purposes of section four, the term ‘Sponsoring Agencies’ refers to Metro South Health and Brisbane South PHN.

1. The grant is to be used solely for the specified purpose outlined in the Grant Guidelines and approved by the Sponsoring Agencies during the funding period.

2. Any changes to the scope of work, funding expenditure and unspent funds require prior written approval from the Sponsoring Agencies.

3. Cessation of activities, including the termination of this Agreement by the Sponsoring Agencies, will require:

(a) the balance of unspent grant monies and property acquired to be repaid and re-allocated to the Sponsoring Agencies unless otherwise agreed to by the Parties.

4. If requested, you must allow the Sponsoring Agencies to appoint an independent auditor, or an authorised representative, to have access to and examine your records and information concerning this grant within ten (10) business days of receiving the request.

5. Payment of funds shall be within 30 business days, following the provision of an Australian Tax Office (ATO) compliant invoice.

6. An acknowledgement of funding assistance provided by the Sponsoring Agencies must be included in any advertising and on any material relating to the project as determined by the Sponsoring Agencies.

7. Any breaches to the terms and conditions of this Agreement will enable the Sponsoring Agencies to terminate without notice.

8. You must comply with all relevant Local, State and Commonwealth laws applicable to the approved purpose.


Section Five – DeclarationThis declaration is made by the applicant (an eligible incorporated organisation or local government authority) or an appropriate sponsoring organisation on behalf of the applicant:

Note for the purposes of section five, the term ‘Sponsoring Agencies’ refers to Metro South Health and Brisbane South PHN.

I declare that I am currently authorised to sign legal documents on behalf of the organisation.

I declare that all the information provided is true and correct.

I declare that the organisation is financially viable and is able to meet all accountability requirements.

I give permission to the Sponsoring Agencies, if applicable, to contact any persons or organisations in the processing of this application and understand that information may be provided to other agencies, as appropriate.

If a grant is provided, I am aware the Grant Conditions as outlined in section four will apply to ensure projects are appropriately completed and accountability requirements are met.

If a grant is provided, I agree to ensure that appropriate insurances are in place (e.g. worker’s compensation, volunteers, professional indemnity, public liability, motor vehicle etc.).

If a grant is provided, I agree to run the project as stated and provide:

a) a final acquittal report, and

b) a statement of income and expenditure (signed by the authorised signatory) to demonstrate how the grant funds were utilised

to the Sponsoring Agencies by the agreed date, which will be outlined in the payment advice letter.

If a grant is provided, I acknowledge the importance of the public interest and my obligation to ensure that any Conflict of Interest issue will be resolved or appropriately managed in accordance with Metro South Health’s Conflict of Interest Policy (PL2015-38).

I am aware that if I have an interest that conflicts, or may conflict, with the receival of grant funding:

a) I must disclose the nature of the interest and conflict to the relevant Delegate within the Sponsoring Agencies as soon as practicable after the relevant facts come to my knowledge; and


b) I must not take action or further action relating to a matter that is, or may be, affected by the conflict unless authorised by the relevant Delegate within the Sponsoring Agencies.

In relation to the receival of grant funding, I declare that:

☐ I do not have a conflict of interest, but if a conflict of interest arises in relation to the receival of grant funding, I will, as soon as practicable disclose the nature of the interest and conflict to the relevant Delegate within the Sponsoring Agencies, and not take action or further action in relation to the receival of grant funding unless authorised by the relevant Delegate within the Sponsoring Agencies; or

☐ I have an interest that conflicts or may conflict with the receival grant of funding, and I will, as soon as practicable, disclose the nature of the interest and conflict to the relevant Delegate within the Sponsoring Agencies, and not take action or further action in relation to the Transaction unless authorised by the relevant Delegate within the Sponsoring Agencies.

Please outline Conflicts of Interest details for recording (add additional pages if required):



Name of the organisation: Click or tap here to enter text.

Legally authorised officer name: Click or tap here to enter text.

Legally authorised officer position: Click or tap here to enter text.

Legally authorised officer telephone: Click or tap here to enter text.

Legally authorised officer signature:

Witness name: Click or tap here to enter text.

Witness signature:

Date: Click or tap here to enter text.

*Important: The application must be signed by the person legally able to enter into contracts on behalf of the organisation. For incorporated organisations this is generally the chairperson, president or equivalent officer. For local government authorities this is generally the chief executive officer. The application may be signed by a formally authorised delegate, according to the organisation’s constitution or as bound by law.

Please note: all formal correspondence will be sent directly to the legally authorised officer.


Section Six – Taxation and bank details of the organisation managing the grant fundsTaxation details

ABN Click or tap here to enter text.

Is your organisation registered for GST?

Yes ☐ No ☐

Bank account details

Bank name Click or tap here to enter text.

Bank branch (suburb) Click or tap here to enter text.

Name of bank account (e.g. Youth Group Inc.)


BSB number(must be six digits)


Bank account number(up to nine digits)


I confirm that the above taxation and banking details are true and correct.

Signature

Date Click or tap here to enter text.


Application Checklist

Before you send your application – please ensure you have completed the following.

Check each item when you have completed or attached it.

Item Check box

1. Completed all questions in the application form. ☐

2. Legally authorised officer has read and completed the declaration in section five of the application form. Where an application is being submitted by an organisation that has a sponsoring organisation, please ensure the sponsoring organisation signs the declaration and banking details.

☐

3. The confirmation of taxation and banking details in section six of the application form is signed.

☐

4. Attach appendices to support your project (i.e. project plan, references, etc.), if applicable. Please list: Click or tap here to enter text.

☐

Enquiries

Should you have any queries regarding the Living Healthier Lives Community Grants program, or this Application Form, please contact the Project Officer on 07 3069 4751.

Please submit completed Application Form to:

Email (preferred): [email protected]

Please ensure that a scanned copy of the signed Declaration page is included, or a hard copy is posted within five (5) business days.

OR

Post: Transformation and Innovation CollaborativeMetro South HealthPO Box 4043Eight Mile Plains Qld 4113


mailto:[email protected]

Documents

Living Healthier Lives Community Grants Program … · Web viewI am aware that if I have an interest that conflicts, or may conflict, with the receival of grant funding: I must disclose