Community Initiative Programme

COMMUNITY INITIATIVE PROGRAMME

FUNDING APPLICATION FORM

Name of ‘not for profit’ Group/Organisation: ______

Contact Person’s Name: ______

Role in Group/Organisation: ______

Address: ______

______

Telephone: ______Email: ______

1. A brief outline of your group / organisation’s aims and objectives (max. 50 words):

2. Describe the proposed initiative for which Funding is sought (max. 100 words):

3. Using the criteria outlined in the Programme Guidelines, explain how your proposed initiative will respond to the needs of the most vulnerable in the community (max 150 words):

a) How will the proposed initiative provide care to those in need and tackle issues relating to disadvantage, poverty, social exclusion, social isolation and/or marginalisation?
b) Are there ways in which your organisation can collaborate with other groups/organisations in your region for this initiative? Explain.
c) How will the proposed initiative be sustained beyond the assistance of the Community Initiative Programme?

Proposed Start date: ______Proposed Finish date: ______

Breakdown of Total Cost of proposed initiative

Item / Total Cost / Funding Sought from Community Initiative Programme
€ / €
€ / €
€ / €
€ / €
€ / €
Total / € / €

Details of other funding which has been sourced, promised or applied for, for this initiative

Source Amount Secured Promised Applied For

______€

ADDITIONAL INFORMATION

Details of any funding your group /organisation has previously sought / received from the Fund, and any additional information you may wish to give

DECLARATION

I confirm that all the information given is true and accurate and that any funding awarded will be used for the purposes for which it was given, and within 12 months of it being awarded.

I commit to submitting a written Evaluation Report within 1 month of completion of initiative (where funding in excess of €1,000 has been awarded), detailing how initiative actually benefitted those in need in the community. In the case of funding in excess of €5,000, the Steering Group will advise on required reporting.

I attach a copy of the up-to-date Child Protection Policy, which has been approved and signed by the management of our group / organisation (where initiative involves children).

I accept that the BSHS Community Initiative Funding Steering Group, reserves the right to decline any Funding Proposal.

Name: ______Date: ______

Position: ______

Please return to:

Completed Applications forms should be sent to only one of the following, selecting the location geographically closest to where your charity/project is based.

Projects with a national profile are sent to the Bon Secours Health System Office Cork.

Bon Secours Care Village, Cork / Sr. Helena Daly, Hospital Mission Leader, Bon Secours Care Village
Mount Desert, Lee Road, Cork

Bon Secours Hospital Tralee / Owen McCarthy, Hospital Mission Leader, Bon Secours Hospital
Strand Street, Tralee, Co. Kerry

Bon Secours Hospital Cork / Ken Joyce, Hospital Mission Leader, Bon Secours Hospital, College Road, Cork

Bon Secours Hospital Glasnevin / Sr. Goretti Spillane, Hospital Mission Leader, Bon Secours Hospital,
Glasnevin, D09 YN97, Dublin

Bon Secours Hospital Galway / Donal O Neill, Hospital Mission Leader, Bon Secours Hospital, Renmore,
Galway, H91 KC7H

Bon Secours Hospital Limerick / Mr. Jason Kenny, Hospital Manager, Bon Secours Hospital, 97 Henry Street, Limerick

Bon Secours Health System / Andrew McCarthy, Group Mission Coordinator, Bon Secours Health System, College Rd, Cork

12 December 2016