The Macedon Ranges and North Western Melbourne. Small Grant Application Form

Transcription

1 The Macedon Ranges and North Western Melbourne Medicare Local Legacy Grants Program Small Grant Application Form

2 MACEDON RANGES & NORTH WESTERN MELBOURNE MEDICARE LOCAL LEGACY GRANTS PROGRAM small GRANT APPLICATION FORM (for Grants up to $20,000) 1. Instructions to Applicants Please read the MRNWM-ML Legacy Grants Program Invitation to Apply & Guidelines as well as the MRNWM-ML Comprehensive Needs Assessment prior to completing this form. Applicants must complete all relevant sections of this application form and sign the declaration at the end. Incomplete applications will be judged accordingly which may affect your success in receiving a Grant. Closing date for applications: 5pm, Friday 4 September 2015 Please submit three (3) hard copies of your completed application (and any attachments) by post to: MRNWM-ML Legacy Grants Program Level 1 Government Pavilion 320 Epsom Road FLEMINGTON VIC 3031 Applications can also be delivered in person to the MRNWM-ML office in Flemington by depositing them in the Tender Box in the Reception Area. Submissions will be acknowledged by , within one (1) working day of being received. For further information and assistance, please contact Dr Vanda Fortunato on (03) or vandaf@mrnwm-ml.org.au 1

3 2. Applicant Details In this section you are required to provide information about the applicant, including contact details of those involved with this application. If you submit an application in collaboration with one or more other organisations, the consortium must nominate a Lead Organisation for the application. 2.1 Applicant Organisation Details (or nominated Lead organisation) Registered Organisation Name: Trading Name of Organisation: (if different from above) Street Address: Postal Address: (if different from above) Telephone: Website: (if applicable) 2

4 2.2 Status of Applicant Organisation Is the applicant registered for GST? Yes No Is the applicant organisation incorporated? Yes No (If No, you are ineligible for funding) Type of legal entity: (Please indicate legal entity type and attach a copy of the current certificate) ABN: ACN: For organisations submitting a consortium application: Ensure that the nominated lead organisation (the applicant) is a legal entity capable of entering into a funding agreement with MRNWM-ML. Attach to the application, a letter of support from each of the consortium member organisations, clearly outlining their role in, and commitment to, the project. 2.3 Contact Details Principal Contact Person The principal contact person is the person who is legally authorised to enter into contracts on behalf of your organisation. The principal contact must complete the declaration at the end of this application form and will be required to sign an Agreement for the Provision of Funding if the application is successful. NB: This is generally an Office Bearer sitting on the Management Committee for example; a Chairperson, President or CEO. Principal Contact Name: Position: Telephone: Mobile 3

5 Project Contact Person (if different from above) This is the person who knows most about the project. Generally this would be the Project Manager. Project Contact Name: Position: Telephone: Mobile 2.4 Insurance Applicants must have current Public Liability Insurance cover to a minimum of $10 million as well as other insurances as necessary and appropriate to the successful delivery of the proposed project. Does the applicant organisation hold a minimum $10 million Public Liability Insurance? Yes No Please provide evidence of your current $10 million Public Liability Insurance You are ineligible for funding Please complete the following table to confirm the apllicant s necessary and appropriate insurance cover for the proposed project. Please attach certificates of currency for each type of cover. Proof of insurance cover: Provider Policy Number Expiry Date Limit of Liability Public liability Professional indemnity Workers compensation Others as relevant Relevant exclusions: (Provide separately a summary of any relevant exclusions to the above, and their potential impact on this project) 4

6 3. Organisation OVERVIEW In this section you are required to provide details regarding the applicant s structures and processes that will ensure the sound running of the project. 3.1 Provide a summary of the kind of work the applicant organisation usually performs. (Maximum 300 words) 5

7 3.2 Governance and Accountability The applicant is required to demonstrate sound Governance structures, processes and controls that comply with relevant legislative requirements and govern how the organisation functions and the capability to make decisions in an accountable and transparent manner. Responses should include, but are not limited to: Details of the organisational structure Evidence of effective and efficient Governance structures e.g. Finance, Risk, Audit, Compliance or equivalent Committees Processes and policies for dealing with conflicts of interest (Maximum 1000 words) For a consortium application, explain the role and function of each member in meeting the agreed requirements (Maximum 400 words per organisation) 6

8 3.3 Financial Capability Provide a summary detailing how the applicant organisation/consortium will implement solid financial processes, sustainability and capacity in making efficient, effective, ethical and economical use of grant money. (Maximum 500 words) The Legacy Program Selection Committee will consider whether any specific conditions need to be imposed as a condition of funding. Please attach the most recent audited financial report. 7

9 4. Project Details In this section the applicant is required to provide specific details on the proposed project, including what the project aims to achieve and in what timeframe. The applicant is required to demonstrate the ability to actively manage the project. When responding, please ensure you address the following to support your response: Relevant expertise; and Specific examples of similar activities that demonstrate experience and capacity 4.1 Project Title Project Title: Project Manager: Endorsed by (Agency CEO): Date: 4.2 Project Rationale Please tick all relevant priority areas that your project will address: Tackling Family Violence Improving Health Literacy Chronic Disease Prevention and Management Improving Access to Maternal and Child Health Services Improving Access to Mental Health Services Other 8

10 Describe the specific health need or gap that your project addresses. NB: Applicant s that focus on other health needs in their proposed project are required to provide compelling evidence of the need in the catchment. (Maximum 500 words) 9

11 4.3 Evidence Base/Needs Analysis Applicants are required to demonstrate a rigorous evidence base for their proposed project, such as Health data Analysis of gaps, needs and demand The applicant is required to show evidence that the proposed project is an effective intervention. The applicant should also consider how to collect information and evaluate the health improvement in the target group as a result of the project. This information should inform and align with your Monitoring and Evaluation Strategy (4.14). (Maximum 2000 words, plus attachments and/or supporting documentation) 10

12 4.4 Project Implementation Aims and Objectives Describe one (1) aim and up to five (5) objectives for this project. Think about the project objectives using the SMART methodology: Specific and Clear (identify what exactly will be realised) Measurable (identify how it will be measured) Achievable (consider whether the goal is realistic and if you have control/influence over it) Relevant and Recorded (provide evidence that the objective is relevant to the Project) Time-bound (determine a time-frame that is realistic) Aims: Objectives: 11

13 4.5 Project Implementation Plan Clearly define the project deliverables and clear timelines. Please include: Key Performance Indicators (ensure these align with the Monitoring and Evaluation Strategy 4.14) Key Project Milestones (Maximum 800 words) 12

14 4.6 Project Management Who is involved in implementing the project and what are their key roles and responsibilities in the delivery of the project? Provide information about the project management approach, structure, staff, volunteers, etc. (Maximum 400 words) If appropriate, please list the Project Leads from consortia member organisations in the table below Name Position and organisation Contact details (phone and ) 13

15 4.7 Collaboration and Community Involvement Outline other groups, organisations or people who will be involved in, or who you have consulted with in regards to this project and briefly describe their involvement or role. Letters of support from external parties demonstrating their involvement and commitment to the project will enhance the application. 4.8 Sustainability Describe how the benefits of this project will continue beyond the funding period. For example, provide evidence of how this project could be integrated or connected to existing services. (Maximum 300 words) 14

16 4.9 Location Within what part of the Macedon Ranges and North Western Melbourne Medicare Local catchment is your project based? NB: If your project does not directly benefit communities within the Macedon Ranges & North Western Melbourne Medicare Local region, the project is ineligible for funding Project Cost Total Project Value: $ Other Income: $ In Kind Donations: (with details) $ Amount requested from the MRNWM-ML Legacy Grants Program: $ 4.11 Project Duration Please specify the duration of the proposed project, eg 6 months, 18 months Project duration dates Eg. November 2015 November 2016 Project duration total 12 months 15

17 4.12 Project Budget Please provide a comprehensive Budget which lists all income sources and expenditure directly related to the delivery of the project. Include a detailed breakdown and description of all project expenses including details of how you calculated any in-kind contributions for the project. All figures must be GST exclusive. The budget must include the amount of funding sought from the Legacy Grants, income from any other sources, and inkind contributions. Please also include the delivery costs, wages and salaries, costs of evaluation and monitoring, etc Risk Management Identify any issues that may affect the capacity of the project to achieve its outcomes Milestone Risk Mitigation Example: Recruit participants to health program Example: Difficulty engaging program participants Example: Engage early with key health services or agencies to develop links and promote program to potential participants. 16

18 4.14 Monitoring and Evaluation Strategy The applicant is required to demonstrate a strategy for measuring the effectiveness of the intervention. How do you plan to collect information and evaluate the health improvement in your target group as a result of your project? (ensure this strategy aligns with your Project Implementation Plan 4.5) (Maximum 1000 words) 17

19 5. Branding If the proposed application is successful, the applicant agrees to acknowledge the MRNWM-ML Legacy Grants Program in written materials, using this statement: This project has been funded by the MRNWM-ML Legacy Grants Program, honouring its legacy of commitment to the long term health of the North-Western Melbourne and Macedon Ranges community. The Applicant agrees to use the required branding 18

20 6. References Please provide two (2) referees for the project: Referee #1 Organisation Name Nature of Work Postal Address Street Address Contact Person Position/Title Telephone Number 19

21 Referee #2 Organisation Name Nature of Work Postal Address Street Address Contact Person Position/Title Telephone Number 7. Application Checklist Before submitting, please check that you have included: Three (3) hard copies of this completed Application Form Letters of Support (if applicable) Evidence of Legal Entity Status Most recent Audited Financial Statements Certificate of Currency of Current Public Liability Insurance and other insurances as necessary and appropriate Copy of the Applicant s Annual Report (if available) Supporting documentation for evidence base/needs analysis 20

22 8. Declaration Please read and sign the following declaration: I am authorised to make this declaration on behalf of the applicant I have read and accept the conditions of funding outlined in the Macedon Ranges and North Western Melbourne Medicare Local Legacy Grants Program Invitation to Apply & Guidelines. I declare that the applicant is financially viable and able to manage the project within the timeframe and within budget. I declare that all information provided in this application is true and correct. I understand that this application does not create a legal or binding commitment, arrangement or understanding between Macedon Ranges and North Western Melbourne Medicare Local and the applicant organisation. Any such commitment, arrangement or understanding will be the subject of further negotiation and documentation, including an Agreement for the Provision of Funding. I also understand that additional specific conditions may be included in this Agreement. I understand and accept that if successful, the applicant may be required to participate in project profiling activities. I understand and accept that decisions of the Macedon Ranges and North Western Melbourne Medicare Local, regarding the Legacy Grants Program, are final and there is no feedback or appeal process. I understand and accept that information provided in this application will be stored by Macedon Ranges and North Western Melbourne Medicare Local and its agency, Victoria University, in various formats including hard copy and/or electronic storage. I accept that if this application is successful, the applicant organisation agrees to acknowledge the MRNWM-ML Legacy Grants Program in written materials, using the following statement: This project has been funded by the MRNWM-ML Legacy Grants Program, honouring its legacy of commitment to the long term health of the North-Western Melbourne and Macedon Ranges community Signed by Authorised Organisation Representative: Name: Position: Signed: Dated: 21

23 9. Submission Applications must be received no later than 5pm Friday 4 September Please submit three (3) hard copies of your completed application by post to: Macedon Ranges and North Western Melbourne Medicare Local Legacy Grants Program Level 1 Government Pavilion 320 Epsom Road FLEMINGTON VIC 3031 Applications can also be delivered in person to the MRNWM-ML office in Flemington by depositing them in the Tender Box in the Reception Area. Acknowledgement of your application will be given by within one (1) working day of receiving submissions. For further information and assistance, please contact Vanda Fortunato on (03) or vandaf@mrnwm-ml.org.au 22