Community support grant application

How did you find out about the Bill Raby Diabetes Fellowship?

Website

Newspaper

Territory Way magazine

Word of Mouth

Other funding recipient

Other…

Applicant Information

(A) Name of organisation applying
The ‘organisation’ is the group applying for the grant and undertaking the proposed project or activity. If incorporated, the exact name of the organisation, as indicated on the Incorporation Certificate, is recorded here.

Name of organisation

ABN

Where is your organisation located

GST Registered

Yes

No

Postal Address

Email address

Contact person: (for enquiries regarding application)

Full name

Telephone No

Email address

Position in Organisation

(B) Are you an Incorporated organisation? (please tick the relevant box below to indicate eligibility)

Incorporated

Please provide a copy of your Certificate of Incorporation

One file only.
10 MB limit.
Allowed types: jpg png pdf doc docx .

Unincorporated

Please provide copies of

Certificate of Incorporation of sponsoring organisation.

One file only.
10 MB limit.
Allowed types: jpg png pdf doc docx .

Project Details

(A) Name of the Project

Please provide the name of the project for which a grant is sought.

(B) About your Project
You can attach more Project information if you have it

What do you want to do?

Where did this idea come from (e.g. members or volunteer’s suggestion, community inquiry)?

What you are aiming to achieve by doing this Project?

Are you working with other organisations on this Project? (Please attached any letters of support from other organisations or groups)

Will you need ongoing support to maintain the work of the Project after the grant has been spent? If so, where will the support come from?

(C) Timing and location of the Project

Please outline when and where the project will take place. Please provide a timeline for the project including a projected start and completion date.

Projected Start Date

Projected Completion Date

(D) Participation

Who will participate in the work of this Project?

(e.g. working group, committee, general public, community members invited to workshop)

How many volunteers and volunteer hours do you anticipate being contributed?

Who will benefit from this Project?

(e.g. neighbouring community, children’s groups)

(E) Evaluation of the Project

Please outline how you will evaluate the success of the project e.g. a debrief with the organisers after the event, asking participants about their experience, feedback from other groups and organisations involved in the project.

(F) Project Reach and Impact

What is the projected reach of your project? This may be described in terms of the number of people, the expected length of the benefit and/or the geographic reach of the project.

If this is an ongoing program, or a program that is anticipated to continue post the grant period, how does the organisation plan to support it longer term?

Budget Details

(A) Project Costs
Please list the costs for your Project with as much detail as you can. If you’re buying equipment, for example, give an approximate cost for each type of equipment. You may attach a detailed budget or quotes.

Re-order	Budget Item	Cost	Weight	Operations
	Budget Item	Cost	Item weight

more items

Total Project Cost

TOTAL Bill Raby Diabetes Fellowship Community Grant sought

(B) Other funding

Is your project eligible for other sources of funding such as the NT Government Grass Roots program or the Community Benefit Fund?

Yes

No

Unsure

Have you made, or do you intend to make, an application for a grant for this project or activity from any other source?

Yes

No

Program Name

Program Source

$ Amount

Date the outcome is expected

Agreement and Declaration

I have been authorised by to make this application.

(name of organisation or sponsor)

Applicant Acknowledgements

I have read and accept the Privacy Statement included in the Administration Section

I have read and accept the Conditions of the Fellowship

I understand that neither Healthy Living NT nor the Fellowship have taken any role in the planning or preparation for this activity and accept no liability in the conduct of the activity.

If successful in receiving funding, at project completion are you / your organisation willing to write a brief project story with photos for the HLNT Territory Way magazine and social media?

State Full Name

Position in Organisation

Signature

Sign above

Date

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