West Lothian Community Health Network

West Lothian Community Health Network


APPLICATION FORM

NHS Lothian

Health Improvement Fund

Oxgangs Community Health

Small Grants

2017

NAME OF ORGANISATION / GROUP
NAME OF CONTACT
Completed Application forms should be returned by email /post to:

Zoe Cairns
Secretary
Health Promotion Service
Canaan Park
Astley Ainslie Hospital
143 Grange Loan
Edinburgh
EH9 2HL
Office Use Only
Date received
Group Score
Amount awarded

INFORMATION ABOUT YOUR ORGANISATION/GROUP

Note: the applicant must be an authorised representative of the organisation/group to benefit by the grant.
1. Name of Organisation / Group
Address for correspondence / Contact Name:
Position in Organisation/Group
Telephone no:
Email:
Postcode: / Fax:
2. How would you describe your organisation/group? Tick as many as apply.
Voluntary Organisation
Self Help Group
Registered Charity Please give your charity number ______
Other: (please state e.g. new group) ______
  1. Does your organisation/group have the following? Tick or fill in as appropriate.

A constitution /  / Bank account in the name of the group 
  1. Please give us a brief description of your organisation’s main aims and activities.

5. / a)How long has your organisation/group existed: ______years ______months
INFORMATION ON HOW THIS APPLICATION WILL HELP YOUR COMMUNITY
6. / Describe how you will use this grant
a)What are you aiming to achieve?
b)What activities will you deliver to achieve this?
c)How will you know your outcomes have been achieved?
d)How will this piece of work tackle health inequalities in your community?
e)Who in your community will benefit if this application is successful?
f)How do you know there is a need for this piece of work?
g)How have you involved local people or client groups in the planning of this work?
h)Which other agencies have you consulted? Which other agencies do you intend to work with?
i)If you receive this grant, where will the work take place?
f) Will your work link with any local health plans/priorities?

PROJECT FINANCIAL INFORMATION

Please send in your last year’s Accounts if you have them or a copy of your latest Bank statement

9 /
Please list each item of expenditure for this project, showing your calculations and please enclose estimates or other evidence of costs, including in kind items..
ITEM / RESOURCE
/
AMOUNT
Sub Total
Total cost of Project
Total grant applied for
Other contributions/ sources of funding for this project, if any. Please give details

10.

Bank Account

Please state the name of the bank account this grant would be paid into if successful. This should be the same as the applicant name.
Name of bank
Bank address
Account name
Bank sort code
Account number
11 / I understand that, should this group receive a grant, we will be required to produce a progress report after 6 months and a final report in April 2019 detailing howthe funding has been used and what outcomes have been achieved as a result.
I acknowledge that the grant will be reclaimed if it is not used for the purpose applied for within 12 months of receipt of the grant.
Signed on behalf of the group by:
Name:
Position: / Date:

Completed, signed application forms should be returned by email or post to:

Zoe Cairns

Secretary

Health Promotion Service

Canaan Park

Astley Ainslie Hospital

143 Grange Loan

Edinburgh

EH9 2HL

Closing date for applications: 4pmFriday 15th December 2017

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