Crisis FundApplication Form

Grants are made to selected charitable organisations and agencies throughout Cornwall for distribution to individuals

Name of organisation

Contact details

Title: Miss/Ms/Mrs/Mr (please circle) / Contact name:
Organisation Address:
Postcode: / Correspondence Address (if different):
Postcode:
Position in organisation
Daytime telephone number
Mobile telephone number
E-mail address
Website / www.
How did you hear about this fund?

About your organisation

Please describe the main activities of your organisation:
When did your Organisation start? (DDMMYY)
Do you have a Set of Rules/Constitution/Governing document? / Yes/No
Do you have a Health and Safety Policy and appropriate Insurance? / Yes/No
If you work with children and young people or are safeguarding adults, do you have Child Protection and Safeguarding Adult Policies respectively? / Yes/No
Have your staff and volunteers all passed DBS checks (previously known as CRB checks)? / Yes/No
Is your Organisation a Registered Charity? / Yes/No
If yes, please enter your charity number
How many members are on your Management Committee, please identify any relationships / Men: Women: Disabled: Young People:

Beneficiaries

What vulnerable groups will you help?(you can tick more than one box)


Elderly people (over 60) /
Babies and young children
People with certain health conditions (e.g. heart
Conditions, hypothyroidism, stroke victims) / People with mental health conditions
(e.g. dementia, mental illness, learning difficulties)

People who are Homeless or are Rough Sleepers /
People who are disabled

People who are in receipt of benefits /
Isolated people who are living on their own
How many people do you expect to help? / ………….….. Beneficiaries

Which geographical areas will you be covering in Cornwall?

Finance

If your application is successful payment will be made via BACs. Please specify your bank details here. / Account Name:
Account Number:
Sort Code:
How much money are you applying for from The Crisis Fund?(Maximum for this application is £250 – further top ups can be requested) / £
Please outline the types of items you will be supporting: (eg. emergency food, mobile phone top-up, electric meter top-up etc.)

Checklist

This application will ONLY be considered if you enclose the following:
  • Aphotocopy of your signed, up to date Constitution/Set of Rules

Declaration

It is essential that you understand and agree to sign up to the following statements. If you leave the organisation or can no longer fulfil your responsibilities, or someone else takes over responsibility for the grant on behalf of the organisation, you must inform us immediately.

Our signatures confirm our acceptance of the conditions below:

  • We agree to abide by the terms and conditions of the grant as they are set out in the application form and the accompanying guidance. If any factors change we will inform Cornwall Community Foundation and understand that all or part of the grant may have to be repaid.
  • We certify that the information contained in this application is correct and that we are authorised by the organisation to accept these conditions on their behalf.
  • If successful we will not use the grant for any other purposes, other than those specified, without first receiving authorisation from the Cornwall Community Foundation. We will not use the grant for goods or services already ordered or purchased.
  • We agree to publicise the Cornwall Community Foundationat any appropriate opportunity including publicising their logos on our website (available from CCF), word of mouth, updates in our publications/circulars etc., sharing information with other community & voluntary groups and press releases.
  • We agree to participate in monitoring, auditing and evaluation relating to this fund.
  • We will keep records of each grant distributed and before handing money over to any beneficiaries we will ask the beneficiary to complete a simple receipt form, provided by the Cornwall Community Foundation, as evidence of spend. This along with a simple End of Grant Report, provided by CCF, should be sent back to the CCF no later than one year from award. However if top-up funds are requested this information should be provided and a top-up will be considered.
  • We will record feedback, quotes and project information throughout the life span of the project to include in the end of grant report.
  • Any photos taken by CCF, or submitted to CCF via Jpegs can be used for publicity purposes unless stated otherwise by the main contact on this application form.
  • We agree to the above for the duration of this award and any subsequent top-ups.

Organisation Chair or Secretary

Name (please print) ______Signature ______Date: ______

Committee member

Name (please print) ______Signature ______Date: ______

Next Steps

Please take a copy of this completed form for your own records. We may ask you to refer to your application form during the application process and you will need to refer to it when filling out an end of grant report at the end of your project.
Please return this original form with the copy of your constitution/set of rulesto:
Cornwall Community Foundation, Suite 1, Sheers Barton, Lawhitton, Launceston, Cornwall PL15 9NJ

If you have any queries regarding your application please contact us on:

01566 779333, by email to

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Page 1 of 3 CCF, registered charity no. 1099977 Crisis Fund Application Form Date created: 16/12/2014