Application Form

Active Minds, Active Bodies Program Initiative 2025 – Stream 3: Community-Led Activity Grants

The Active Minds, Active Bodies Community‑Led Activity Grant Program supports organisations to develop inclusive, community‑driven initiatives that enhance physical activity, social connection, and wellbeing for older Australians. Funded activities must be culturally safe, locally relevant, and responsive to diverse needs, including Aboriginal and Torres Strait Islander peoples, CALD communities, LGBTQI+ individuals, and those living with chronic conditions.

Applications will remain open until 9:00am, Monday 23 March 2026 9 am.

Applicants are required to read the Grant Guidelines before applying. Submission of a signed online application does not guarantee funding. WNSW PHN reserves the right to request changes to the proposed activity prior to approval.

Funding of up to $5,000 (excluding GST) is available per eligible organisation.

APPLICATION DETAILS

Legal Name of Organisation: *

Trading Name of Applicant (if applicable):

Do you have an ABN? *

Yes No

ABN: *

Are you registered for GST? *

YesNo

If Other, please specify *

Street address *Street address line 2

City *

State *

Postcode *

Briefly describe your organisation (no more than one paragraph) *

APPLICATION CONTACT DETAILS

In this section you are asked to provide contact details of your organisation's authorising officer and/or key contact person for this application. The authorised contact person is the person who is authorised to sign a funding agreement on behalf of your organisation, should your application be successful.

Authorised Person’s name: *

Authorised Person's Position title: *

Authorised Person's Email Address *

Authorised Person's Phone number *

The application contact should be the person we will contact for any issues related to the application and project activity:

Application contact person: *

Application contact person position title: *

Contact Person's Email Address *

Contact Person's Phone number: *

ELIGIBILITY CRITERIA

Does your organisation demonstrate relevant experience in delivering community programs and activities for older people? *

YesNo

Does your organisation meet one or more of the following eligibility criteria? (Mark all that apply) *

Community based organisations ie Neighbourhood centre/hub, Lions, Rotary, Country Women's Association (CWA), Men's Shed, etcCommunity Non-profit Organisation.Local Councils.Primary health care practitioners.An Aboriginal Community Controlled Health Organisation (ACCHO).Community group without an ABN applying under auspice arrangements.

Holds Public Liability Insurance (minimum coverage $10 million) *

YesNo

Holds Professional Indemnity Insurance (minimum $10 million coverage). *

YesNoNot relevant

Location of the organisation. *

Far West LGA's -Unincorporated NSW, Broken Hill, Central Darling, Balranald, WentworthOrana LGA's - Lachlan, Cobar, Brewarrina, Coonamble, Walgett, Bogan, Warren, Bourke, Gilgandra Narromine and Warrumbungle ShireOther.

If "Other" please provide the location. *

If selected, our organisation commits to completing the proposed project with in 06 months period ? *

YesNo

Details of Proposed Activities

1.What is your proposed activity, and how does it promote social connectedness for older people? (Alignment with Program Objectives - Weight: 10 *

2. Describe how you will engage community members, including older people from diverse backgrounds. - Weight: 20 *

3. Please provide a plan for your activity, including a timeline and the resources required to deliver it.- Weight: 20 *

4. What similar activities have you or your organisation delivered in the past? - Weight: 10 *

5.How will this activity continue once the funding period ends?- Weight: 20 *

6. To help WNSW PHN understand the impact of this program, please explain how you will collect participant feedback, attendance data, and positive stories from your community - Weight: 20 *

ACTIVITY BUDGET

Please provide a breakdown on how you intend to utilise the funds.

Expense Type *

Description of expenses *

Budgeted Amount (excl GST) *

Total Amount Budgeted $ (excl GST) *

DECLARATION

This section must be completed by an authorised representative of the organisation submitting the application.

I declare that:

I confirm the contents of this application are to the best of my knowledge accurate, complete and do not contain any false, misleading, or deceptive misrepresentation, claims or statements. *

I have read, understood, and agree to the Grant Guidelines, should this application be successful. *

I declare that the organisation is financially viable and able to manage the funding within the timeframe and within budget. *

I understand that the evaluation decision is final, and no correspondence will be entered into. *

I understand and accept that information provided in this application will be stored by WNSW PHN in various formats, including hard copy and or electronic. *

I confirm that this application does not duplicate existing funding, service delivery or ongoing operational costs. *

I agree to contact WNSW PHN should I become aware of any changes to information contained in this application. *

I understand that this application does not create a legal or binding commitment. *

If the application is successful, I acknowledge that:
- The organisation will be asked to sign a Grant Agreement with the WNSW PHN;
- The organisation will be asked to sign a statement stating they have used the funds in accordance with their application;
- The organisation will provide reports to the WNSW PHN in accordance with their grant agreement; and
- The organisation agrees to maintain adequate insurance for the duration of this grant agreement and provide WNSW PHN with proof when requested. *

I understand if the conditions of the funding are not complied with:
- The WNSW PHN will recover the funds allocated; and
- The WNSW PHN may terminate the grant agreement with the applicant. *

I have read the WNSW PHN General Grant Conditions *

Applicant Signature *

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Please complete the CAPTCHA challenge below to verify that this submission is being made by a human applicant. * *

Name *

Position *

Date: *

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