Wandsworth CCG Community Grant Scheme 2017

Application form

Contact person’s details for this project
  1. Name :
  2. Email:
  3. Telephone number:
  4. Role within the organisation:

About the organisation
  1. Name of organisation:
  1. Address:
  1. Telephone number:
  1. Email:
  1. Website:
  1. Facebook:
  1. Twitter:

  1. What type of group or organisation are you?
  • Charity:
  • Non-for-profit group:
  • Community group:
  • CIC:
  • Other:
  1. Please enter your organisation’s registration number (if you have one)
  1. Is your group part of a larger regional or national organisation?
  1. Has your group or organisation received funding before from the NHS?
If yes, please state the year and amount you were given
  1. Please state how your organisation is currently working with isolated and hard-to-reach members of the community

  1. Which groups of people will benefit from your project? (tick x as appropriate)
•Children and young people
•Adults
•Older people
•People with mental health issues
•People with learning disabilities
•People with physical disabilities
•People with a long term condition
•People with a terminal illness
•People on low incomes
•Homeless people
•Black, minority or ethnic groups
•Lesbian, Gay, Bi, sexual people
•Gender or Transgender people
•Other (write below)
  1. How many people do you think will benefit from your project? (estimate)
  1. Which group will benefit most from your project? (tick x as appropriate)
•0 – 4 Early years
•5 – 12 Children
•13 – 18 Young people
•19 - 25 Young adults
•25 - 64 Adults
•65+ Older people
  1. Please describe your project (max. 200 words)

  1. Why are is your organisation best suited to undertake this project?

  1. How will you know if your project is helping people to achieve better health and care? (We would like to see tangible numbers in relation to Wandsworth residents)

  1. How will you measure the benefit or success of your project? (Please note that strong measurement will assist you in sustaining your project)

  1. How will you promote equality and diversity through this project? It is not enough to say the project is open to all or that your organisation does not discriminate - what measures will you take to ensure that this project promotes equality, diversity, and inclusion

  1. Please tell us of your plans to continue this project after the funding is finished.

Project budget
  1. How much funding are you applying for?(Please note that although the maximum fund amount is £2500, you are welcome to apply for less if your project can accommodate this.)

Please use the space below to show what you will spend the money on.

DescriptionAmount

Renting space / £
Bills / £
Fees / £
Staff / £
Equipment / £
Marketing / £
Other / £
£
£
£

Requirements

To ensure that there is sufficient governance and assurance, we will often ask for details of your organisation. We recommend that you prepare the following information, as we may request it when assessing your application.

  • Copies of financial record keeping and expenditure
  • A set of rules or constitution outlining governance arrangements
  • When your group/organisation started
  • Your charity or CIC number (if applicable)
  • Names and addresses of all management committee members, with cheque signatories identified.
  • Child Protection or vulnerable adult protection policy (if you are working with these groups)
  • Health and Safety Policy

DECLARATION:

  1. I am authorised to make an application on behalf of the above organisation
  2. I certify that the information contained in this application is correct
  3. If the information in this application changes in any way I will inform
  4. I give permission for NHS Wandsworth CCG to record the details of my organisation electronically and to contact my organisation by phone, mail or email with information about its activities and funding opportunities
  5. I/We(The organisation) will attend a minimum of four CCG Meetings- including one where we do a presentation on how we have used our funding.
  6. I /We(The organisation) will attend a minimum of two patient Meetings
  7. I/ We (The organisation) will provide updates on the funded project as required and provide a written final report on our funded activity.
  8. This will include photos, quotes, and receipts if required.

Signed: / Date:

Referee

Please give the name and contact details of someone outside of your organisation who has agreed to be an independent referee for your application.

Name: Link to group/occupation:
Address:
Postcode
Telephone: / Email:
Signed: / Date:

Chair: Dr Nicola Jones Accountable Officer: Sarah Blow

Better care and a healthier future for Wandsworth

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