Application Form

Primary Health Care Vaccination Grants Program 2025 - New Vaccinators

To be eligible for this grant, applicants must be a general practice, Aboriginal Medical Service, or pharmacy that is not currently providing COVID-19 vaccinations and agree to stock and administer them.

Applications will remain open until 5:00pm, Friday 20 June 2025.

Applicants are required to read the Application Guidance 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 $2,000 (excluding GST) will be made available per application.

All activities must be completed within three months, and payment will be made upon submission and acceptance of evidence that the applicant has been stocking and administering COVID-19 vaccinations.

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 *

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

Please select the type of primary health care association *

General PracticeAboriginal Medical Service Pharmacy

I am registered with the relevant governing body ie. AHPRA *

YesNo

I am an authorised immunisation provider and comply with NSW Health legislation within the Western NSW PHN region *

YesNo

If I am not an authorised immunisation provider, I agree to become one and to comply with NSW Health legislation. *

YesNoNot Relevant

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

YesNo

Hold Professional Indemnity Insurance *

YesNo

COMMITMENT TO PROJECT SCOPE

If selected for the Primary Health Care Vaccination Grants Program for New Vaccinators, we agree to; Commence stocking and delivering COVID-19 vaccinations; and Stock and administer COVID-19 vaccinations for a period of at least six months. *

YesNo

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 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 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 *

I have read the Grant Guidance Application *

Applicant Signature *

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Name *

Position *

Date: *

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