2017/18 APPLICATION FORM

Sport and Recreation Development and Inclusion Program

BEFORE YOU START

Putting together a strong application takes time and energy, so it is important that you read the guidelines carefully, complete this application in full, and ensure that all of the information to be submitted with your application(see table below) is provided.

ASSESSMENT CRITERIA

Eligible applications will be assessed on the answers provided in this application form and whether the project meets the following assessment criteria:

  • need, scope and value of the program/project
  • immediate outcomes for the Recreation and Sport Industry/Community
  • applicant’s contribution and proven capacity to administer and deliver programs/projects
  • sustainable and long term outcomes for the organisation/Recreation and Sport Industry/Community.

INFORMATION TO BE SUBMITTED WITH YOUR APPLICATION

Advice Notes / Item / Checked
‘Certified’ requires that the President/Treasurer sign the Annual Financial Statement
If your organisation is registered on MyRecSport, you do not need to provide this item. / Your most recent annual financial statement certified by the President /Treasurer or audited by a qualified accountant.
NOTE: Bank statements and bank reconciliation reports will not be accepted
A completed “Proposed Action Plan and Budget” (refer Attachment 2)
Evidence of other confirmed contributions (refer question 24) / NA
Where applicable, letters of support for the project from each of the user groups(refer question 16) / NA
If you received funding for this project in the 2016/17 round of the SRDIP, provide a brief report on what outcomes have been achieved to date. / NA
A completed EFT form - refer Attachment 1 (if applicable) / NA

IMPORTANT PROJECT ELIGIBILITY QUESTIONS

Is your project being delivered state-wide?Yes - No

Is your project aimed at ‘Inclusion’?Yes - No

(if you answered ‘No’ to both of the above questions please contact a Funding Consultant on 1300 714 990prior to completing the application form)

Are you a club delivering a ‘club-based’ project?Yes - No

(if you answered ‘Yes’ to the above question please contact a Funding Consultant on 1300 714 990prior to completing the application form)

Advice Notes
Holding a Gaming Machine Licence does not preclude your organisation from applying. /
  1. Is your organisation a holder of a Gaming Machine Licence?

YES (Holding a Gaming Machine Licence does not exclude you)
NO
If your organisation is registered on MyRecSport, answer question 2 and then proceed to question 9
As it appears on your Certificate of Incorporation
If you are unsure of your ABN, please visit the Australian Business Register at
If you are a local council or school leave question 3 blank. /
  1. Name of Organisation:

If you are unsure of your ABN, please visit the Australian Business Register at
If you are a local council or school leave question 3 blank. /
  1. Does your organisation have an Australian Business Number (ABN)?

YES (provide number):
NO
If you are unsure, please call the Australian Taxation Office on 13 72 26. /
  1. Is your organisation GST registered?
YES
NO(see Guidelines for information on ‘Grants and the GST’)
The Child Safe Environment Compliance Statement must be lodged with the Department for Education and child Development (DECD) to acknowledge that the organisation meets the obligation of the Children’s Protection Act 1993.
Further information available at or call (08) 7424 7622 /
  1. If the organisation wholly or partly provides services to members or participants under 18 years, does it or its governing body hold a ‘Child Safe Environment Compliance Statement’?
YES
NO
Not Applicable(We do not provide services wholly or partly to members or participants under 18 years’)
  1. Street address and details of your organisation:

Street Address:
Suburb/Town:
Postcode:
Phone: / (08)
Fax: / (08)
Email:
  1. Postal address of your organisation (if different to above):

Address:
Suburb/Town:
Postcode:
All application correspondence will be directed to the person via the postal/email address provided. /
  1. Name and details of contact person for this application:

Title:
First Name:
Surname:
Position:
Phone: (b/hours) / (08)
Mobile:
Email:
We will use this name on all correspondence. Please use 10 words or less (eg.Youth Frisbee Program). /
  1. Project name:

For organisations submitting multiple Sport and Recreation Development and Inclusion Program applications. /
  1. Project priority?(Rank in numerical order of importance. For example: Priority 3).

Priority / Your priority will be taken into consideration, however, please note that ORS may deem a lower priority project to be more appropriate forGovernment funding.
  1. Which region(s) will you be delivering this project in?
State-wide / OR
Metropolitan / Greater Metropolitan / Regional
Eastern Adelaide / Adelaide Hills / Eyre and Western
Northern Adelaide / Barossa, Light and Lower North / Far North
Southern Adelaide / Fleurieu and Kangaroo Island / Limestone Coast
Western Adelaide / Murray and Mallee
Yorke and Mid North
Please identify which gender and age groups the project will target (select all that apply). /
  1. Who will the project target?

Male / Female
0-4 / 5-12 / 113-18 / 119-25 / 26-54 / 55+
Please provide the number of people for each year if you are applying for multiple year funding. /
  1. How many people do you expect to benefit from the project?

Year 1
Year 2
(if applicable)
Year 3
(if applicable)

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Funding is only available for projects that commence once a grant agreement has been finalised and will be conducted beyond 1 July 2017. /
  1. Project Timelines:

Estimated Start Date:
Estimated Completion Date:
Your outline should describe what you are going to do. This may include areas such as:
-the activity
-regularity of sessions
-length of the project
-number of people targeted
-where it is located
-how it will be promoted
-who will deliver the project /
  1. Describe the project (see Advice Notes on left)

Who are the project partners and what do they bring to the project. /
  1. Detail any stakeholders involved in this project

Partner organisation
e.g. Multicultural Council of SA / Tasks / skills / expertise
e.g. Promoting project to target group
What is the rationale or reasoning behind your organisation wanting to undertake this project.
What gap does the project address in your organisation or the wider community. /
  1. What is the demonstrated need this project addresses?

You should be able to clearly demonstrate how this project fits into your current Strategic Plan.
How will it help you achieve the Strategic Plan outcomes and reach your future goals. /
  1. How does this project link to your Strategic Plan?

What evaluation method will be used and what measures will be considered a success. /
  1. What are the project outcomes and how will you measure their success?

Project Outcome
e.g. Increase number of coaches in the Barossa region / Performance Measure
e.g. 30 new coaches
Explain how the project will be sustainable in assisting you to increase members/ participation numbers for the long term. /
  1. If successful, how will you continue the project without future Government funding?

If applicable, provide with your application a letter of support for the project from your peak body. /
  1. If you are affiliated with a peak body, explain what level of support the peak body is providing?

Please note if you ticked no and your project is successful, you will be required to undertake a child safe risk assessment on your project as a condition of your grant agreement. /
  1. Have you undertaken a child safe risk assessment for the project?

Yes
No
Not applicable to this project
Only provide the contact details of the person who will be managing this project if it is someone from outside your organisation. /
  1. Who will be managing the project?
Our organisation will manage the project
Other (provide details below)
Contact Person / Name of organisation / Contact phone number
Attachment 2 to be completed with details relating to the project and associated costs and mustbe submitted with the application.
If your organisation is GST registered costs are to be GST exclusive
Evidence of confirmed contributions (eg. Letter of confirmation) /
  1. What are your project costs?

2017/18 2018/19 2019/20
Total Project Cost: / $ / $ / $
Our organisations contribution: / $ / $ / $
Other confirmed contributions: / $ / $ / $
Amount requested from ORS (Maximum $100,000) / Amount of funding requested: / $ / $ / $
Provide detail on the number of staff and the expected number of hours to be worked each week.
Further information on ‘Awards’ can be found at /
  1. Will your project include the employment of staff?
Yes (complete questions below)
No
If Yes, please provide the number of staff to be employed.
Casual / Part Time / Full Time
Estimated hours to be worked per week
Which ‘Award’ the employee(s) will be covered by?
Final checklist before submitting your application
We have completed all relevant sections of this application form
We have attached all supporting material requested in this application form.
Instructions
  1. The declaration below must be read and signed by two authorised representatives of your organisation
  2. At least one representative must be a member of the Board / Management Committee.

Declaration by authorised persons
I make the following declaration:
  1. I am duly authorised by the organisation to prepare and submit this application
  2. This organisation is eligible to apply for funding in accordance with the eligibility criteria in the Funding Guidelines
  3. The responses in this application and all supporting documents provided are to the best of my knowledge true and correct
  4. I understand that the Office for Recreation and Sport may disclose the information provided in this application to other Government agencies, Local Government, reviewers and staff assisting with the administration or promotion of State Government Grant Schemes
  5. I understand that information in relation to this project will be made public in the event that the application for funding is successful (refer to the program guidelines)
  6. Where required, our project will comply with all the relevant codes, standards and applicable legislation including, but not limited to, the Disability Discrimination Act and the Children’s Protection Act 1993.

Signature 1: / Signature 2:
Date: / Date:
Name: / Name:
Position: / Position:
Please forward this completed application and all attachments to:
BY POST:
Applications post marked on or before the closing time and date will be accepted.
Sport and Recreation Development and Inclusion Program
Office for Recreation and Sport
PO Box 219
BROOKLYN PARK SA 5032 / IN PERSON:
Hand delivered applications must be received by 5.00pm Monday 5December 2016.
Sport and Recreation Development and Inclusion Program
Office for Recreation and Sport
27 Valetta Road
KIDMAN PARK SA 5025
LATE APPLICATIONS MAY NOT BE ELIGIBLE FOR FUNDING CONSIDERATION
Applications close 5:00pm Monday 5 December2016
Telephone: 1300 714 990 Web:
It is anticipated that applicants will be notified of the outcome by31 March 2017
Procure to Pay
Vendor Creation/Amendment Form with EFT Details
Vendor Details
Agency: / Office for Recreation and Sport / Department: / DPTI
Create New Vendor / Amend Vendor / Purchase Order related / Non Purchase Order related
(i.e. Online Payment Request)
Vendor Code (if known)
Vendor Type / Grants / Employee ID
Payment Details (Business/Individual)
Australian Business Number (A.B.N)*
Business Name
First Name / Surname
Address/PO Box
Street Address
Suburb / State / Post Code
Fax Number / Phone Number / Mobile Number
Email Address
* Where a Vendor (business or individual) has supplied goods or services to the payer and is not required to quote an Australian Business Number (ABN), aStatement by a
Supplier form is required. Withholding tax is applied if the Vendor does not supply a valid ABN orStatement by a Supplier form.
EFT Bank Details
BSB Number
Account Number
Financial Institution
Street Address
Shared Services SA reserves the right to suspend the EFT payment system and pay by cheque at its discretion.
Conditions:
Payment will have been deemed to be made when Shared Services SA has instructed the appropriate banking authority to credit the above account. Shared Services SA will not
be responsible for any delays in the payment or errors due to factors outside of its control including delays or errors in the banking systems or errors in the account details supplied. Shared Services SA has the right to accept the authority of the undersigned as conclusive of that person's authority to execute this agreement on behalf of the vendor.
The vendor agrees to repay the Shared Services SA any payments credited to the vendor in error. Shared Services SA reserves the right to offset any amount paid in error against future payments.
Requested By: (Agency use only)
I have confirmed all details including EFT details are correct with the vendor.
Name / Database Officer, Funding Services / Phone / 47 609
Signature

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‘Attachment 2 - Proposed Action Plan and Budget (2017/18 SRDIP)

Organisation Name:

Project Name:

Action / Resource(s) required / Budget / Timeline / Measurable Outcome(s)
Eg. Promote Program / Organisation staff / $2,000 / 31 May 2014 / 1,000 flyers distributed
Eg. Deliver program / Volunteer/Program Coordinator / $5,000 / 31 August 2014 / Conducted 6 session/300 participants

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