APPLICATION FORM MEMORY CAFÉ/DEMENTIA SUPPORT GROUP GRANT

Transcription

1 APPLICATION FORM MEMORY CAFÉ/DEMENTIA SUPPORT GROUP GRANT Name of group Is this a new group? Details of main contact Contact name Contact address Postcode Position in group (e.g. member, Chair, Treasurer, etc) Daytime telephone number Mobile telephone number address How did you hear about this fund? About your group Please describe the main activities of your group Which geographical area(s) are you working in? Please tick to confirm your group is not commissioned by NHS Kernow, Cornwall Council or IOS Council Does your group have a bank account? This is essential and the bank account must be in the group s name. Have your volunteers all completed a DBS check? This is a requirement of funding. For new groups, the grant can fund these costs. Does your group have Public Liability Insurance? This is a requirement of funding. For new groups, the grant can fund these costs. Page 1 of 4 CRCC charity number Memory Cafe/Dementia Group Grant Application Date updated 18/10/2013

2 About your group Please tell us about the group for which you are seeking funding. Please include the following information and continue on a separate sheet if needed The date the group started Where the group will meet How many people you expect to benefit How the group and its activities will support people living with dementia What activities and resources are/will be available to the group How people with dementia will be involved in the planning of activities and decisions about the spend What fund-raising activities the group will be involved in How people with dementia will be involved in the planning of activities and decisions about the spend What fund-raising activities the group will be involved in What other groups you are working with, if relevant Your group must have a steering group or committee. Please tell us their names and the positions they hold. Name Position 6. Page 2 of 4 CRCC charity number Memory Cafe/Dementia Group Grant Application Date updated 18/10/2013

3 Your group must link to 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 this is and ask them to sign below. Name of professional Organisation name Organisation address incl postcode Daytime telephone number address Website Reference signature: I can confirm that I work for the above named organisation and have checked that my organisation is on the list of approved providers. I also confirm that I know of and support this group and its activities. Signed: Date: Finance - if your application is successful, payment will be made by BACS How much money are you applying for? Max 400 per 12-month period Have you received this grant from us before in the last 12 months? If yes, how much have you already received? What is your group s bank account name? Bank account number Please specify the payee name Bank sort code Who are your account signatories? Please provide a breakdown of TOTAL costs for your activity or event, highlighting what you want this grant money to be specifically spent towards. Type of cost. Total cost (inc. VAT) e.g. venue 15 per week x 50 weeks Total costs for group Page 3 of 4 CRCC charity number Memory Cafe/Dementia Group Grant Application Date updated 18/10/2013

4 Declaration/ Agreement Name of the group: Our signatures confirm our acceptance of the conditions below: We agree to abide by the terms and conditions of the Memory Cafe/ Dementia Support Group Grant as they are set out in the guidelines that accompany this application form. Any offer of a grant will be subject to our proposed activity or event remaining within the grant criteria. We understand that the grant must be spent for the approved purpose and that failure to do so could result in a request for funds to be returned. If our circumstances change and we wish to amend our original activity, we will notify CRCC in writing detailing the proposed change and will await approval by the grant panel before proceeding with the new activity. We understand that this will only be in exceptional circumstances. We must complete and send the CRCC progress reports when requested, together with evidence of spending this grant e.g. copies of receipts, invoices, etc, no later than 6 weeks after the planned activity has taken place. We agree to CRCC using our information for publicity related to this fund. We confirm all the information provided in this application is true and accurate. Signed Print name Position Date Checklist 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. Please ensure your referee has signed where requested Page 4 of 4 CRCC charity number Memory Cafe/Dementia Group Grant Application Date updated 18/10/2013

5 Memory Café/Dementia Support Group Grant Grant Guidance Notes 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 Cafe/ Dementia Support Group Grant? It is the aim of the Memory Cafe/ Dementia Support Group 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 maxiumum of 400 per 12-month period. New groups can apply for a start-up grant of 300; the remaining 100 will be allocated upon receipt of a progress report. Groups may apply more than once per year to a maximum of 400. Groups can apply in partnership with each other but each group can still only receive 400. 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. Volunteers must have DBS checks and the group must have Public Liability Insurance. New groups can use the grant to fund both of these 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 must not exceed 400 per year. Facilitations costs are not included. Travel expenses are not included, including to meetings and conferences. Groups that do not deliver activities for people with dementia including those that 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, DBS checks, 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.

6 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 End of Grant Report. 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: 29 November March 2014 The grant panel will meet 2 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. Please note that this will only be in exceptional circumstances. Monitoring and evaluation Groups must agree to complete an End of Grant Report on a standard form supplied by CRCC. The End of Grant Report must be completed no later than 6 weeks after your project end date. 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: grants@cornwallrcc.org.uk Data Protection 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). Helping Hand Whilst your group does not have to hold these policies, it is good practise to do so. If you would like help or advice in relation to any of these, please get in touch. Safeguarding Adults Health and Safety Policy Group Constitution We may also be able to provide advice on: how to manage group finances, facilitation skills, group ground rules, etc. Please let us know if you need help with these or any other matters in running a group.