Small Grant Application Form

Small Grant Application Form

Small Grant Application Form

PROJECT NAME AND LOCATION
1. Project Name
2. Which area is your project in? (please name the streets and/or area that will benefit)
APPLICANT DETAILS
3. Organisation Applying:
4. Name of main contact:
5. Position within/relationship to organisation:
6. Applicant Address:
Postcode:
Tel:
Email / 7.Correspondence Address: (if different)
Postcode:
Tel:
Email: / 8. Preferred method of contact
Post
Phone
Email
9. Type of organisation:
(double click in the box that applies to you, and then select ‘Checked’)
Community Group / Voluntary Group / School
Partnership / Other (Please State):
If you are a registered charity or your organisation has some other kind of registration, please give us the number here.
AMOUNT OF GRANT
10. How much grant money are you asking for from us in total? £
THE PROJECT
11. Project Description – Tell usabout what you plan to do, how you will do it, where you will do it and when you will do it.
If you are a school, please confirm whether you intend to link your project to Walk to School Week 2015 (May 2015.Final date tbc)
Yes No
11a. Start date:
11b. Finish date:
(if the project is taking place on one day these two dates should be the same)
12. How will this projectencourage more people to walk more often in your area?
13. Key milestones: please enter in the table below your project’s key milestones (notable activities) and the date by which you intend to achieve them. If your project is taking place on one day please say so:
Key Milestone / Target date
Project Start
Project Finish
14. What evidence is there to support what you want to do? Please give us details to show us that your project is needed. If you need to give us extra information, like a survey or letters of support, please include them as attachments and tell us here what you have attached.
Has your project been identified as part of a community street audit?
Yes No Not sure
15. We need to be sure that your project will not duplicate or conflict with anything that already exists.
Are there or have there been any similar projects in your area? Yes No
If you ticked Yes, tell us how your project is different to these projects:
Are you working with other organisations on your project? Yes No
If you ticked Yes please give the name(s), contact details and roles of the organisations here:
Organisation / Contact details / Role
16. Does the project require consents or permissionssuch as planning permission? If unsure, please contact your Local Authority.
Yes
No
16a. What stage have permissions reached?(please cross one box, and give all dates)
Not applicable / Not yet approached / In progress / Complete
Planning Permission
Licensing
Landowner’s consent
Other statutory permissionPlease state below what this is:
FINANCES
17a. What is the total project cost? £
17b. How much grant money do you want from CityConnect Walking? £
17c. Expenditure
  • List all the individual items or activities that make up your project.Please include VAT
  • Include everything you need, even if you are not asking us to fund it.
  • You must not claim from us any VAT that you can claim back from HM Revenue and Customs.
  • Make sure that the costs are accurate and based on quotations. If the cost for a single item is below £500 please tell us how you arrived at your costs. If the cost of a single item is from £501 - £2,000 you need to get at least 3 quotations or list prices.
Please check that you have added up your totals correctly
Item or activity / Total Cost / Grant Requested from
CityConnect Walking / Amount of funding from other sources
£ / £ / £
£ / £ / £
£ / £ / £
£ / £ / £
£ / £ / £
£ / £ / £
£ / £ / £
£ / £ / £
£ / £ / £
£ / £ / £
TOTALS / £ / £ / £
17d.Please tell us how you arrived at your costs. Please provide evidence in the form of copies of quotations or list prices

17e. What percentage (%) of the total project cost will the CityConnect Walking Grant be?
If less than 100% please complete section 17f.
17f. Where will the other funding come from and is it secured yet? Please list all other funders, including your own funds if appropriate. You will need to provide evidence that it is secured before a grant can be offered e.g. a letter. Continue on a separate sheet if necessary.
Funding Source / Amount / When was the money secured?
RISKS
18. What are themain risks that could occur during your projector could prevent your project happening, and how will you deal with them? Continue on a separate sheet if necessary
RISK / CONTINGENCY PLAN
17. EQUAL OPPORTUNITIES AND CHILD PROTECTION
19a.Will your project be open to all? If not please explain who your project will be restricted to and why.
19b.Does your project involve working with children, young people or vulnerable adults?
Yes No
If so please provide a copy of your Child Protection Policy and DBS details.
DECLARATIONS
Data Protection
The information you submit on this Application Form will be held by CityConnect and its partners within the project
It will contribute directly to the decision that is made regarding allocation of funding. If you are awarded funding, the information you have supplied will form part of your grant contract.
Declaration: I confirm that all information within this application form is accurate to the best of my knowledge and I am authorised to apply for funding on behalf of the organisation/ group. I understand that if successful I will be responsible for completing an End of Grant Monitoring Form.
Signed ………………………………………………..
Name …......
Position in Organisation…......
Additional Information
If you have any further information that you feel we should be aware of please include it with your application and tell us what you have included here:
Checklist Please ensure you have
  1. Completed the application form in full and signed the application form
  2. Provided copies of initial quotes for items of expenditure
  3. Provided Letters of support or Evidence of need
  4. Provided evidence of funding applied for/ secured
  5. Provided copies of Permissions if applicable
  6. Provided copies of your Child Protection Policy and Disclosure and Barring details
  7. Provided further information if applicable

Small Grant Application Form

Please return this application form by 5pm on 16th January 2015:

by email to

or by post to:

John Kilner

Living Streets Project Coordinator

CityConnect Team

West Yorkshire Combined Authority

Wellington House

40-50 Wellington Street,

Leeds LS1 2DE

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