Small Grants Programme - Application Form

Instructions for completing your application:

-  Please type your responses

-  Please ensure you answer all the questions and ensure that you complete the budget template

-  Please attach all required documents

-  Please send all of the above to

Application Form

Project title:

Legal name of organization:

Country:

Total grant requested:

Proposed start date (month/date/year):

Proposed end date (month/date/year):

Date of proposal submission:

Area of support requested for in line with the True Colours Trust criteria (tick which appropriate funding area you have applied for)

·  Equipment for patients

·  Palliative care for children and young people

·  Palliative care medicines

·  Capital improvement costs

·  Increasing access to palliative care in rural areas

·  Training courses for palliative care service providers held in Africa

Grantee Information:
Person Responsible for project
(only one individual may be identified) / Institutional contact
(person responsible for official signature, financial reporting and correspondence)
Name:
Title:
Dept.:
Institution:
Address:
Tel:
Fax:
Email: / Name:
Title:
Dept.:
Institution:
Address:
Tel:
Fax:
Email:

Has this organization received funding from the True Colours Trust in the past?

Yes______No______

If yes, please provide the title of the project funded, the amounts received and the year of funding.

Please keep in mind that there is a time lag of 1 year in between possible grants for the same organization (this 1 year period starts from the day the final narrative and financial report has been received and approved by APCA).

Application Format

I.  Project aim: In 1-2 sentences, please summarise what you expect this project to achieve. (Aim of the project).

II.  Background Information on the Organisation: Please provides a brief description of the organisation, and what you do. Explain how this proposed project fits in with the overall aim of the organisation. (2 paragraphs).

III.  Project justification: Please explain the need that your project will help to address

IV.  Project Summary: Please provide a brief summary of the project by answering the following questions. Please note that for training activities an additional training sheet will need to be filled in, which can be found in annex 2.

a.  What are the objectives of the project?

i.  Main objective

ii. Specific objectives

b.  Where will the project take place?

c.  What activities will you undertake?

d.  What are the methods you will use for this project?

e.  Who will your project benefit: list the number of people you will reach: how many men? How many women? How many children? Are they from urban or rural areas?

f.  Who will be involved in the project (please mention the names of staff, their titles and function within the project, as well as other possible involved persons, such as trainers) ?

g.  What are the results that you expect at the end of the project?

h.  Please indicate in the table below, which indicators you will be using to measure success. You can choose from the given indicators, but can also fill in additional indicators in the spaces below. Please also provide your expected target.

Project Indicators / Target
Number of eligible adults and children provided with palliative care services
Number of home based care follow up visits conducted to patients
Number of people sensitised in palliative care
Number of people trained in palliative care provision
Number of eligible children provided with paediatric palliative care services
Number of children receiving psychosocial support
Number and type of equipment purchased
Number of people receiving palliative care medications

V.  Project implementation work plan

Please provide a timeline for each of the proposed activities in the table below.

Activity / Month of implementation (put an x in the box that corresponds to the month that the activity will happen) 1= first month of the project
(list one activity per line) / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10 / 11 / 12

VI.  Project management: Who will manage the grant? Explain the skills of staff involved and their roles in the project (1 paragraph)

VII.  Sustainability: Please describe how this project will be sustained in the future (if the application is for an ongoing piece of work rather than equipment costs)

VIII.  Previous donors: Please provide information on donors who previously funded your organization in the last three years

Donor name / Amount provided / Project name / Duration / Donor contacts;
Name of contact person, Email and Telephone

IX. Budget: Please use the budget template in annex 1 to show the amounts you need for each item. You can add more lines if needed. Please include the exchange rate from your local currency to English pounds (GBP)

BANK NAME:

Bank Information: this is the account the funds will be sent to if your application is successful

ADDRESS:

SWIFT/ABA CODE:

ACCOUNT CODE:

ACCOUNT BENEFICIARY:

Additional Information required

In order for your application to be considered, you must also submit the following documents. Please check the box if these documents have been attached.

Document required / Check
Copy of registration of the organization confirming that it is a legal entity in the country of operation
Reference letter from the national palliative care association, or, if there is no association in your country, then obtain a reference from another recognised health institution such as the Ministry of Health or a Hospice and palliative care programme.
Proof of registration of the person responsible with the relevant professional body/council such as the Medical Association.
Copy of a valid work permit if the responsible person is not a national
Proof of employment with the organization of the person responsible for the project
Current Audited Accounts for your organisation (if not available explain why you cannot provide them)
Budget template (annex 1)
Training sheet (annex 2)
Equipment quotes (2 per item)
ANNEX 1. Budget Template
Organisation Name:
Project Name:
Project Period:
Total Budget Request:
GBP Exchange rate used:
Description of Activity / Unit of measure / Qty 1 / Qty 2 / Unit cost in local currency / Overall totals in local currency / Total cost in GBP Pound:
Activity 1: / How many? / How often will you need them?
Sub total
Activity 2:
Sub total
Activity 3:
Sub total
Activity 4:
Sub total
ADMINISTRATIVE COSTS
Sub Total
Grand Total

Notes on the budget template:

Qty (Quantity) 1: Number of items required

Qty (Quantity) 2: If required more than once (frequency of occurrence, number of times item is required)

Unit Cost: Cost in Local currency for each item

Overall total: Total per line item in local currency

Exchange rate with the GPB: Total per line item in local currency divide by prevailing exchange rate of the GBP in your country

Subtotal: Totals per activity in the budget

Grand total: Total of all sub totals in the budget.

ANNEX 2. Training sheet
Training title
Purpose of the training
Methodology to be used
Key expected outputs/
outcomes
Trainers to be used (how many, name, function)
Proposed duration of training
Overall topic
Specific topics to be covered during the training
Nr of participants and please indicate targeted group (such as community members, religious leaders, health care staff, volunteers, etc)