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APPLICATION FORM
MEMORY CAFÉ/DEMENTIA SUPPORT GROUP GRANT 2014 – 2015
Have you applied before to this grant this year? Yes [ ] No [ ]If yes, when did you apply (month/year)?
Name of group:
Is this a new group? Yes [ ] No [ ] If yes, expected start date
Contact details
Contact name:
Contact address:
Postcode:
Telephone number(s):
Email address:
Can we add you to our mailing list to receive our newsletters? Yes [ ] No [ ]
We put basic information about groups we fund into our Speaking Up magazine and on our website so that other people can find out about groups that may help them. Please tell us here the information you are happy to have published.
Contact name (not essential)
Contact number
Contact email address (not essential)
Group website (if applicable)
How did you hear about this fund?
Please tick to confirm your group is not commissioned by NHS Kernow, Cornwall Council or IOS Council [ ]
Does your group have Public Liability Insurance? Yes [ ] No [ ]
This is a requirement of funding. For new groups, this grant can fund these costs
Does your group have its own bank account? Yes [ ] No [ ]
This is essential and the account must be in the group’s name
About your group
Please describe your group, what does it do, any particular activities.Please tell us about the activities or events for which you are seeking funding. Please include the following information and continue on a separate sheet if needed:
· The date the group started / expects to start
· Where the group will meet
· How many people you expect to benefit (please specify how many people with dementia, how many carers, how many volunteers)
· How the group and its activities will support people living with dementia
· How people with dementia will be involved in the planning of activities and decisions about the spend
Your group must have a steering group or committee. Please tell us their names and the positions they hold.
Name Position
1.
2.
3.
4.
Finance
If your application is successful, payment will be made by BACSHow much money are you applying for?
Max £400 per 12-month period. New groups can apply for an additional £300 start-up grant. / £
Name of bank/building society:
Bank account name:
Bank account number:
Sort code:
This grant
Please provide a breakdown of all costs for your group below, highlighting what you want this grant money to be specifically spent on.Type of cost
e.g. venue hire @ £15 per week / Total cost £ (inc. VAT)
Total cost / £
Reference
Your group must have the support of a local professional or a recognised organisation who can vouch for your group (please see the list of eligible organisations in the guidance notes). Please tell us who they are and ask them to sign below.Name of professional
Organisation name
Organisation address incl. postcode
Phone number
Email address
Reference signature: I can confirm that I work for the above named organisation and have checked that my organisation is on the approved list of providers. I also confirm that I know of and support this group and its activities.
Signed:
Date:
Declaration/Agreement
Name of your group:· I agree to the terms and conditions of the Memory Café/Dementia Support Group Grant as they are set out in the guidelines that accompany this application form.
· I understand that if my group is given a grant, we will only use it for the item or activity stated in this application form. If we need to use the money for something else, we understand we must get permission from CRCC first.
· I agree to complete a feedback report on how the grant was spent and how it has helped the group, and agree to send in all relevant receipts.
[ ] Please tick: I confirm that the information provided in this application is true and accurate to the best of my knowledge.
Name:
Date:
Checklist
Please tick to say that you have completed the following:
[ ] Please ensure all sections of the form are completed and you have signed the agreement above
.
[ ] Please check the application guidelines carefully, particularly the Eligibility Criteria and Exclusions.
Next steps
Please take a copy of this completed form for your own records. You may be required to refer to your application form during the application process.
Please post to: Grants, CRCC, 2 Princes Street, Truro TR1 2ES
If you need to call us, our number is: 01872 243532
The application deadlines for this year are:
3 June 2014 29 August 2014 21 November 2014 20 February 2015
Data Protection
This information will be stored electronically and will remain confidential to CRCC. We will seek your written agreement before using it for any purpose other than that described herein (such as use by a third party).
Memory Café/ Dementia Support Group Grant
Grant Guidance Notes
If you need help with your application
Our Peer Support Co-ordinator is able to assist with the application process; you can contact her on 01872 243559. She can also give information, advice and practical support to all new and existing mental health self-help groups on areas such as:
· how to set up a group
· where to get alternative funding
· how to write a group constitution
· how to set up a bank account.
Cornwall Rural Community Council
CRCC is a Cornish Charity that informs and guides local groups and individuals to achieve their aspirations and develop sustainable, inclusive communities. CRCC provides support to a wide variety of groups and individuals and embraces equality and diversity. The support can be, for example, with rural communities, minority and excluded groups, BME communities, those in poverty or unemployed, providing a voice for those with views on health and social care services and also enabling community groups to bring to fruition community projects and social enterprises.
What is the Memory Café/Dementia Support Group Grant?
It is the aim of this grant to allow groups of people with dementia to run engaging and meaningful activities to enhance people’s health and wellbeing, to assist people with dementia in accessing a range of local support networks and community resources, and so help people with dementia to increase their independence and reduce the need for specialist care or hospital services.
Groups can apply for a grant to a maximum of £400 per 12-month period. New groups can also apply for a start-up grant of £300 in addition to the £400; we will issue the start-up grant first, then groups can apply for the remaining £400 afterwards subject to our receiving a satisfactory progress report. Groups may apply more than once per year to a maximum of £400 (£700 for start-up groups).
Eligibility criteria
• Groups must have a minimum of 4 people and people with dementia must make up the majority of group members.
• Groups must be based in Cornwall and only benefit residents of the county.
• Groups must demonstrate that they support people with dementia and promote their health and wellbeing.
• Groups must have a steering group or committee and provide details of this.
• Applications must also demonstrate how people with dementia will be involved in decisions about the planned activities.
• Groups must link to a professional or recognised organisation who can vouch for the group and be willing to sign the referee statement on page 3. The professional or organisation must be from:
* NHS provider
* Cornwall Council
* IOS Council
* Age UK Cornwall
* Arts for Health
* Memory Matters SW
* Alzheimer’s Society
* Volunteer Cornwall
* CRCC
• Groups must provide details of the intended expenditure and must have a bank account in the group’s name.
• The group must have Public Liability Insurance. New groups can use the grant to fund this and we will require evidence in a progress report that this has been done.
Exclusions
• Applications that make no reference to the aims and objectives of the grant will not be accepted.
• Applications from each group must not exceed £400 per year (£700 for new start-up groups).
• Facilitations costs are not included.
• Travel expenses are not included, including to meetings and conferences.
• Groups cannot apply if they do not support people with dementia or if they support people with memory loss due to neurological disorders.
• Groups where the number of people with dementia are in the minority.
• Groups must not be commissioned by Cornwall Council, NHS Kernow or IOS Council.
• Items and activities already paid for cannot be reimbursed through this grant.
Guidelines
• The grant will fund: start-up costs, resources or expertise, equipment, PL Insurance, training, guest speakers, consultancy, venue hire.
• Grants must be spent on the activities or resources approved and applications must detail how the grant will benefit people with dementia according to the aims above.
• Groups must keep all receipts and invoices relating to this grant.
• CRCC will require a progress report after 6 months and an End of Grant Report to be completed by the organisation once the activities or events have taken place, to be submitted along with relevant receipts and invoices. You might wish to send in
photos and testimonials to support your report.
Next steps
Once we have received your application we will check it meets the above criteria; we may contact you by telephone to discuss the application in more detail. Therefore please ensure the contact provided is available during office hours and has knowledge of your group. We recommend that you take a copy of your application form, as you will need to refer to it if we have any queries and when completing your Progress Reports. Following this initial check, your application will go before the grant panel who will decide on its suitability for funding.
The application deadlines for this year are:
3 June 2014 29 August 2014 21 November 2014 20 February 2015
The grant panel will meet approximately 3 weeks after each deadline to assess applications. You will receive the result of your application in writing within 5 working days of the assessment and, if successful, an offer letter will be sent outlining any conditions of your grant. Decisions by the panel are final and there is no right of appeal.
Change of Grant use
The grant must be spent for the approved purpose and failure to do so could result in a request for funds to be returned. If your circumstances change and you wish to amend your original activity, you must notify CRCC in writing detailing the proposed
change and await approval by the grant panel before proceeding with the new activity.
Monitoring and evaluation
Groups must agree to complete a Progress Report and an End of Grant Report on a standard form supplied by CRCC. The reports must be completed no later than 6 weeks after receipt. When returning the form please include copies of receipts and invoices obtained for all items purchased. No further grant applications will be considered until this has been received and approved by CRCC.
Need more information?
If you need more information please contact:
CRCC
2 Princes Street
Truro
Cornwall
TR1 2ES
Tel: 01872 243532
Email:
1 CRCC charity number 1087550 Memory Café/Dementia Group Grant 2014-15