Hebden Bridge Hub, Staying Well

Part 1: About You / Your Organisation

Name of Organisation(as it appears for banking purposes)
Name of Applicant
Position in Organisation
Address for Correspondence
Phone Number
Email Address
Number of active members in your group
Average number of regular users
Do your members pay a membership fee? / Yes/No / Please state amount / £
Do your members pay an attendance fee? / Yes/No / Please state amount / £
Does your group have a Constitution? / Yes/No / Is there a dissolution clause? / Yes/No
Does your group work with Children and/or Vulnerable Adults? / Yes/No / Is there a Safeguarding Policy? / Yes/No
Where do most of your members come from(please specify town and/or village):

Part 2: About Your Project

Please give a full description of the project for which funding is requested (continue overleaf ifnecessary):

Start Date / Finish Date
Project Description:
(please use continuation sheet if necessary)
Who will benefit from your project?
Projected number of new users? / Approximate total number:
Age Ranges of projected new users:
Under 16 / 16 – 25 / 25 – 50 / 50 – 65 / 65 – 75 / Over 75
Where will your new users come from? (please specify town and/or village):
Number of volunteers that will deliver your project?
Estimated number of new volunteers?
Cost breakdown (please give as much detail as possible about the cost of your proposed project)
Amount / What for
Total cost of project: / £
Amount requested from Hebden Bridge Hub: / £
Other Income
Amount / Source
Signature of person completing this form:
Date: / Position in your group:

FUNDING CHECK LIST

DOCUMENTS ENCLOSED / Yes / No
1. / Signed application form
2. / Copy of Audited Accounts(or appropriately verified and signed accounts by an independent assessor) providing the organisation has been in existence for at least 18 months. Or, if the organisation has been in existence for less than 18 months evidence that a separate bank account has been opened with at least two signatories, a recent bank statement not less than 3 months old and a 12 month income and expenditure forecast.
3. / Constitution or aims and objectives of organisation (the constitution must be signed and dated at the time adoption or amendments and include a suitable dissolution clause.)
4. / Child Protection / Safeguarding Adults Policy (required for any project or organisation working with children and/or vulnerable adults)
5. / List of officers of organisation with contact details
6. / Details of project (if there is additional information not included in the application form)
Please tick appropriate box.
If there is a ‘no’ response, an explanation is required:
Any award is made at the discretion of the Hebden Bridge Hub Staying Well project and subject to a funding agreement.
I/We* have read and understood the criteria. (*delete as appropriate)
Name(s) / Signature(s)
Date / Name of Organisation

Please return your completed application form, document check list and all documents requested by 5pm Friday 27 March 2015 at the latest to:

Staying Well, The Town Hall, Saint George’s Street, Hebden Bridge, HX7 7BY, or email

Hebden Bridge Hub Staying Well funding applicationPage 1 of 3