Seeding Grant Application Form - Rockdale City Council

Community Seeding Grants2013/2014 Application___Prior to completing the seeding grant application form, it is advisable that you read the Rockdale CityCouncil’s Community Grants Programme guidelines. Seeding Grants are a one off grant up to the value of$5,000, to establish a new social, cultural, community or leisure programme that will have enduringcommunity benefit.The information provided is used as the basis to form an assessment of the application in accordance withCouncil’s Community Grants Programme Policy.YOUR CONTACT INFORMATIONMr / Mrs / Miss / Ms – Name:(circle)Position:Organisation:Address:P/CodeMailing Address:P/CodePhone: (Business hours)Mobile:Email:Fax:ABN:Privacy StatementThe personal information provided on this form (including your name and otherdetails) will be handled in accordance with the Privacy and Personal InformationProtection Act 1998 and may be available to the public under various legislation.Refer also to the Privacy Statement on Council's website.Rockdale City CouncilOffice: 8.30am – 4.30pm (Mon-Fri); 9am – 1pm (Sat)2 Bryant Street / PO Box 21, Rockdale NSW 2216rcc@rockdale.nsw.gov.au www.rockdale.nsw.gov.auTel 02 9562 1666 Fax 02 9562 1777ABN 66 169 730 052Form reference13/82624 @Sept2013

Page 2 of 6ELIGIBILITY1. Is your club / organisation a business, private or profit organisation,government agency? IF YES YOU ARE NOT ELIGIBLE2. Is your club / organisation a non profit, not for profit, charity, association orcommunity service organisation? Please provide documentary evidence.3. Is the group, club or organisation services located outside the City ofRockdale Local Government Area?4. Is the programme or service an already identified responsibility of agovernment agency? IF YES YOU ARE NOT ELIGIBLE5. Will the club / organisation / group receive funding through other variousfunding bodies for the project? IF YES YOU ARE NOT ELIGIBLE6. Will the grant fund a fundraising organisation or an applicant for fundraisingdrives? IF YES YOU ARE NOT ELIGIBLE7. Can the club / organisation fund the programme through available financialresources?8. Is the club / organisation involved in a political party or group associated withpolitical parties? IF YES YOU ARE NOT ELIGIBLE9. Does the club / organisation have an outstanding acquittal form for pastCouncil grant funding programmes? IF YES YOU ARE NOT ELIGIBLEYesYesYesYesYesYesYesYesYesNoNoNoNoNoNoNoNoNoClub / Organisation Description Please detail the current service, target group/s and mission /vision of the club / organisation.2013/14 Seeding Grants Application Form

Page 3 of 6PART ONE – Programme Support Does the grant request support or service the following(please tick)Purchase of equipment to provide an activity? Yes NoSupport the conduct of an inaugural specific activity or event in the category ofcommunity, social, cultural or leisure?Produce a new information resource for either a community, social, cultural, leisureprogramme?Where will this service / equipment / programme be used?YesYesLocationNoNoProgramme NameProgramme Description – Explain what project you are planning to undertake.Attach supplementary documentation if required. Do not include budget details here2013/14 Seeding Grants Application Form

Page 4 of 6PART TWO – Selection CriteriaQ1) Are the majority of members or participants residents of the City of Rockdale?No Yes Approximate number of the community to benefitQ2) Who will the grant request benefit most within the community and how?Please explain how the need or issue was identified and how the grant will address that need.Q3) How does the grant request improve or increase community access and equity and/orreduce social isolation? Please explain what will you do to engage the community?Q4) What evidence supports the grant request will meet or target an identified and/oremerging issue or need of the local community? Demonstrate ability to meet projects plans as well asaims. Evidence may include feedback, questionnaires, improvements, statistics etc2013/14 Seeding Grants Application Form

Page 5 of 6Q5) How does the grant request promote health, well-being or lifelong learning?Please explain how the grant will encourage community health and promote wellbeing or lifelong learning that will havean enduring community benefit.Q6) How does the grant request encourage community collaboration and sharing of resources?Please explain how the grant will promote the development of partnerships and access to opportunities and resourceswithin the community.PART THREE – Project Budget. Please outline below the project budget for your proposal, includingfunding requested from Council and any other support funding.BUDGET BREAKDOWNGrant RequestIn-Kind orContributionN.B. Ongoing operating costs or staff salaries will not be fundedTOTAL $ $2013/14 Seeding Grants Application Form

Page 6 of 6PART FOUR – AuthorisationI, ________________________________________________________________(Name)certify that I have read and understand the Community Grants Programme Policy 2010 and have beenauthorised to make this application. I agree to abide by the conditions and acknowledge that the statementsmade in this application are true and accurate.Name: _________________________________________________________________Position: ________________________________________________________________Signature: _______________________________________________________________Date: __________________________________________________________________Witness Name: ___________________________________________________________Witness Signature:__________________________________________________________Date: _____________________________________________________________ChecklistAre all contact details accurate? Yes NoHave you attached supporting documentation? (finance, registration etc) Yes NoAre all sections completed? Yes No2013/14 Seeding Grants Application Form