Give Me 5 for Kids Funding Application Form 2015
Give Me 5 for Kids Funding Application Form 2015 BEFORE FILLING OUT THIS FORM: 1. Please have information on your organisation and the aim(s) and benefit(s) of your project ready to insert. The more thought you have given to your submission prior to completing this form; the quicker it will take to complete. All questions need to be completed. Application must be in by 15th May 2015. 2. Once completed, please post application form and all MANDATORY documents to: 2GO Give Me 5 For Kids Attn: Stephanie Zalfelds PO Box 564 Gosford, NSW 2250 3. If you experience any problems with this form, please contact 2GO’s Give Me 5 For Kids on 02 4304 4200 1. Are you a not-for-profit organisation? YES NO 2. Is your organisation a Type 1Deductible Gift Recipient (DGR) entity? NO YES What is the date of the DGR endorsement? 3. Is your organisation an incorporated entity? YES NO 4. Does your organisation meet the 2GO Give Me 5 For Kids Criteria included in the front of this application? YES NO NOTE: PLEASE DO NOT PROCEED WITH THIS APPLICATION UNLESS YOU HAVE ANSWERED YES TO ALL THE ABOVE QUESTIONS 5. Full registered name of your organisation 6. Your organisations mission statement. Central Coast Radio ABN: 580 692 99225 2GO’S GIVE ME 5 FOR KIDS FUNDING CRITERIA For the purpose of clarification for the allocation of funds the following criteria should be met: A child is babies in-utero and children to 16 years of age. Must aid in the improvement in the quality of life for children. Children must be the primary and only client for 2GO Give Me 5 for Kids. The Charity receiving funds must be a Central Coast Charity. The charity can be a national charity but must have a branch that resides on the Central Coast. The allocation of funds for equipment can only be made when the child is the primary and only client and the child only uses the item. Your charity must be a not-for-profit organisation. Your charity must be a registered organisation/charity. Central Coast Radio ABN: 580 692 99225 7. Please supply the address of the premises your organisation runs from. Address Suburb State Postcode 8. Who will be managing your project? Title Given Name Surname Position Phone Mobile Fax Email 9. Nominated representative for correspondence Same As Above Title YES Given Name Surname Position Phone Mobile Email Central Coast Radio ABN: 580 692 99225 Fax 10. Australian Business Number (ABN) or Australian Company Number (CAN) 11. Website address 12. Please supply a description of your organisation and its focus. 13. Project name 14. Please provide a detailed description of the aims and objectives of the project Central Coast Radio ABN: 580 692 99225 15. Category Health Disability Equipment Other 16. Is this a new or existing project? New Existing 17. What date do you expect the project to commence? NOTE: Successful applicants will be notified by 1 June 2015. All projects must be substantially commenced within 12 months of the payment of grant monies. Grant monies will be paid to successful applicants 4-6 months after funding submissions are received. If you are unable to meet this requirement, please provide an explanation below. 18. What is the primary purpose of the project you are seeking funding for? Central Coast Radio ABN: 580 692 99225 19. Does this project have a life beyond this grant? YES NO If yes, please state how you anticipate funding this program beyond this grant. 20. Will the project use the services of volunteers? 21. Do you believe your project will generate media interest or coverage? 22. Total cost of the project $ Central Coast Radio ABN: 580 692 99225 23. Level of grant applying for : Bronze - $5,000 Silver - $10,000 Gold - $15,000 24. Has your organisation requested funding from any other parties in respect to this project? If yes, please provide details. 25. Referee #1 Name Organisation Central Coast Radio ABN: 580 692 99225 Position Phone 26. Has your organisation received any grants previously from 2GO’s Give Me 5 For Kids? Please provide details 27. How did you hear about 2GO’s Give Me 5 For Kids? TV Internet Newspaper Direct Mail Radio Charity (If so, please specify) Other 28. Do you have any other comments you’d like to add to support your submission? Central Coast Radio ABN: 580 692 99225 29. You declare that the information in this application is accurate and that you: * have read and understood the Children’s Fund Applications Criteria laid out in this form * have read the Children’s Fund Applications Criteria YES NO All applicants must review the Children’s Fund Applications Criteria. This agreement sets out the conditions of funding and will form the basis of a legally binding agreement between 2GO’s Give Me 5 For Kids (“2GO GM5”) and the successful applicant(s) unless otherwise determined by 2GO GM5. A legally binding agreement will not be formed until the Agreement is executed by 2GO GM5 and the successful applicant(s). If you will not comply with all condition of this Agreement then you are to submit a statement of noncompliance. This statement must address each clause of the Agreement that you will not comply with. This statement is to be provided as a separate document and form part of your application. Signed Name Central Coast Radio ABN: 580 692 99225 Date
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