Community Chest Application Form

Please read the guidance notes before filling in this application form. If you have any questions, contact us on 020 379 63147. You should send the completed form to Community Chest Applications, Public Engagement Team, The Francis Crick Institute, 1 Midland Road, London, NW1 1AT or to .

The Crick’s Community Chest is supported by the Rangoonwala Foundation

Name of organisation/group Address

Postcode:
Phone: / Website:

Name and address of contact Daytime contact details

Phone:
Email:
Position in the organisation:

About your organisation/group

When was your organisation/group set up?
What are your organisation/group’s main activities?
Does your organisation/group have a set of rules or a constitution?
If YES, please include these with your application / YES NO
Is your organisation/group a registered charity? / YES NO
If YES, what is your registered charity number?
Do you have annual accounts?
If YES, please include the latest accounts with your application / YES NO

Bank Account Details

Account Name:
Account Number:
Sort Code:
Name of Bank/Building Society:

About your project

What is the title of your project?
Please give us an overview/general description of the project.
What is the aim of the project?
Who is it aimed at? For example, children, older people, people living in a particular area
How many people will take part in the project?
How will you make sure people know about and can take part in the project?
When will the project take place?
Where will the project take place?
Why do you think this project is needed?
What difference will this project make to your community?
How will you check to see how successful your project has been?
How much money do you want? (max £3,000)

Please give us a breakdown of how you would use the money

(i.e. the project costs that will be covered by the Crick funding. This could include things such as room hire, staffing, training or equipment costs, publicity etc. Please be as specific as possible, for example “Room hire £20 per week x 10 weeks = £200”. Costs should include VAT where this is applicable.)

Item / £
TOTAL / £

Further information

If there is any more information you feel is relevant to this application please tell us here. You can continue on a separate sheet if you need to.

SIGNATURES

We confirm that to the best of our knowledge all the information given in the Application Form is true and correct. We agree on behalf of our organisation/group to comply with the conditions of the grant set out below.

1. Name:
Position in organisation/group: / Signature:
Date:
2. Name:
Position in organisation/group: / Signature:
Date:
CHECKLIST
Have you completed all the questions on the Application Form?
Have you signed the Application Form?
Have you enclosed your:
·  Constitution/rules
·  Latest Statement of Accounts (if you have these) /
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1
1
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Conditions of the grant

We will:

·  use the grant only for the purpose set out in our application and approved by the Crick

·  comply with any relevant legislation that affects the project, eg health and safety, protection of children, adult safeguarding

·  ensure that the planned activity does not discriminate on the grounds of gender, gender identity, race, religion or belief, sexual orientation, age, or disability

·  unless otherwise agreed, acknowledge the Crick’s support in any marketing and publicity materials as appropriate. (You are under no obligation to use the Crick’s logo in any marketing and publicity materials, but if your organisation/group wants to use the logo you must follow the Crick’s brand guidelines and the Crick’s communications team must sign off material before it goes to print)

·  complete a project evaluation form

·  provide a set of annual accounts or an independently examined and evaluated financial statement within 9months of the end of the financial year of grant funding clearly showing the income and expenditure associated with Community Chest grant

·  tell the Crick if we receive funding for the same project (or for the same elements of the project) from another source. If we receive more funding than we need for the project, we may have to repay part or all of the grant to the Crick

·  tell the Crick if we think we won’t spend the full grant by the end of the grant period.