Do You Have a Constitution? Yesno

Name of Group:

Contact Person:

Address:

Post code:

Contact tel no:

Email:

Do you have a Constitution? YesNo

Do you have a bank account? YesNo

ETHNICITY INFORMATION OF APPLICANTS AND GROUPS BEING SUPPORTED BY THE GRANT

This information will support your application for the funding criteria for Black and Minority Ethnic Groups in Trafford. We have given some examples but recognise these do not cover all communities and ethnic identities of people living in Trafford.

Applicant / Tick / Applicant / Tick
White British / MIXED HERITAGE
English / White and Black Caribbean
Irish / White and Black African
Scottish / White and Asian
Welsh / Caribbean and Asian
Other (specify)
...... / Any Other Mixed Background (specify)
......
Black / Black British
Bangladeshi / African
Chinese / Caribbean
Indian / Jamaican
Pakistani / Somali
Other (specify)
...... / Other (specify)
......
Eastern European / OTHER ETHNIC GROUP
Polish / Gypsy/Traveller
Romanian / Iranian
Russian / Israeli
Other White European / Kurdish
Any other Eastern European ethnic group (specify)
...... / Other Middle Eastern: i.e. Iraqi, Lebanese, Yemeni, Libyan (specify)
......
Any other ethnic group (specify)
......
Communities Intending to Support / Tick / Communities Intending to Support / Tick
White British / MIXED HERITAGE
English / White and Black Caribbean
Irish / White and Black African
Scottish / White and Asian
Welsh / Caribbean and Asian
Other (specify)
...... / Any Other Mixed Background (specify)
......
Asian / Asian British / Black / Black British
Bangladeshi / African
Chinese / Caribbean
Indian / Jamaican
Pakistani / Somali
Other (specify)
...... / Other (specify)
......
Eastern European / OTHER ETHNIC GROUP
Polish / Gypsy/Traveller
Romanian / Iranian
Russian / Israeli
Other White European / Kurdish
Any other Eastern European ethnic group (specify)
...... / Other Middle Eastern: i.e. Iraqi, Lebanese, Yemeni, Libyan (specify)
......
Any other ethnic group (specify)
......

1. Activities of your Group / Organisation

What are your experiences of wellbeing and promoting the management of memory loss?
What are the activities that you need funding for? Will your activities support:
List Activities
Early intervention &prevention
Support & managing memory loss
Which area of Trafford will the activities take place?
What is the start date for your activity and how long will it run for?
How many people could your activity reach / support?
Would you like to access a Dementia Friends or Dementia Awareness session? Or other related training session; Please state:

1. Assistance Needed

What other support do you need to get started? / Who could you ask to provide this?
What do you need the funding for?
e.g. 5,000 leaflets / How much will it cost?
e.g. £300.00
Total

1. Supporting people to manage Memory Loss and Wellbeing

How will your activities make a difference to memory and wellbeing?

Many people experience memory loss as they get older and may feel anxious and/or become isolated. These grants are to support community initiatives that connect people who want to prevent memory loss, currently have memory loss or are people impacted by this. Activities can range from:

• Prevention: being active, community based initiatives that improve wellbeing, good health & lifestyle.
• Awareness: Increasing awareness to groups of all age in particular intergenerational activities.

1. What are the aims and outcomes of your proposed activity

What would your activity achieve?

Signed……………………...... …………………………………………

Position in Group………………………………...... …………………………….

Date

Date Received…………………………………...... …………………………….

6. Evaluation of Your Activity

How do you know you have made a difference?

Here are some suggestions for getting feedback from your target group.

Which ones will you use to get this information? / Tick / How will you keep a record of this information?
Discussion in group
Suggestion box
Video clips of people talking about what they have got out of being involved
Written comments
Other (please Specify)

Post or hand completed forms to:

Jessica Lacey

Old Trafford Community Wellbeing Centre

54-56, Seymour Grove,

Old Trafford,

Manchester.

M16 0LN

Email completed application forms to:

If you have any enquiries:

Telephone: 0161 912 4828

Application forms and guidance notes can be downloaded at:

Deadline for applications 1st March 2016

Applicants will be notified if they have been successful the week beginning 28th March 2016

Application for Grants to support Black and Minority Ethnic Groups in Trafford to promote Wellbeing & the Management of Memory Loss

Feb 2016 1