Application Form

Community Wellbeing Grants – NSW Mental Health and Wellbeing Flood and Disaster Recovery - WNSW PHN

Complete grant applications up to $10,000 in value will be evaluated as they are received, and the outcome will be determined within 15 business days. Applications between $10,001 (ex. GST) and $20,000 (ex. GST) will be assessed after closure of the grant round. Please allow a minimum of three weeks from the grant closure date for outcomes of applications to be announced.

An additional funding round will only be made available if all grant money has not been fully allocated during this grant period.

Applicants are required to read the Guidance Application before applying. Submitting a signed application does not guarantee funding. WNSW PHN reserves the right to request changes to the activity prior to approval.

Applications for funding up to $10,000 assessed as received and until funding exhausted.

Applications for funding of $10,001- $20,000. close 15^th January 2024

All activities need to be completed and funds expended within 6 months of the funding agreement. This cannot be any later than 30 June 2025.

APPLICATION DETAILS

Organisation or Community Group name: *

Address: *

ABN: *

Are you registered for GST? *

YesNo

Auspice details if applicable: *

Auspice Address: *

ABN of Auspice organisation: *

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/community group, should your application be successful.

Authorised person’s name: *

Position title: *

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: *

Email Address *

Phone number: *

OTHER REQUIRED INFORMATION

Provide a summary demonstrating your alignment with Community Wellbeing Grants – NSW Mental Health and Well Being Flood and Disaster Recovery- Western NSW PHN overarching objective and principles, please consider the eligibility criteria, as per the guidance document: (e.g. Applicant must demonstrate their motivation, enthusiasm, community drive, understanding of the needs of affected communities within the WNSWPHN region etc.)

What is the exact amount of funding you are applying for? (GST exclusive) *

Please tell us which community/communities your application covers (include Town/Suburb & Postcode):) *

Do you have any partner organisations for this activity? *

YesNo

ACTIVITY DETAILS

Anticipated activity Start date: *

Anticipated activity End date: *

Name of your Activity: *

Please specify if 'other':

BANK DETAILS

Bank Account Details (leave blank if being auspice. Bank account details must match invoices provided)

Account Name:

BSB:

Account Number:

INSURANCE DETAILS

I have Public Liability Insurance (minimum coverage $10 million) *

YesNo

I have Workers Compensation Insurance (if applicable) *

YesNoNot Applicable

I have Professional Indemnity Insurance (if applicable) *

YesNoNot Applicable

Please provide information about the proposed activity and how it will help to improve mental health and resilience including key focus areas of young people, older residents, and Aboriginal Communities in our region including the estimated number of participants. *

Please outline describe the evidence of need within the communities related to the impact of the floods. Include the impact, expected outcome and benefits and the community groups that will benefit *

How will you measure the success of the Activity in relation to the expected benefits? Please include tangible numbers. For example, number of participants, feedback surveys, quotes from participants etc *

I have completed all elements on the Application Checklist *

I have read the WHAL General Grant Conditions *

I have read the Guidance Application *

Please upload the Activity Budget *

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Please upload your signed Declaration *

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Please upload a letter of support *

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