Main contact (Full Name) *
Position held in organisation *
Are the contact details for this person different to the main organisations details (to be entered below)? * No Yes
Number of paid staff in organisation *
Number of volunteers in organisation *
Names of Account Signatories *
Aims or purpose of your organisation *
(Please include a brief history; number of members/clients and/or groups that benefit from your activities)

Project details:

What is the title of your project? *
(Please give your project a working title)
When will your project start? *
(DD/MM/YYYY – applications can take up to 12 weeks to process and your project must NOT start before this)
When will your project end? *
(DD/MM/YYYY – Please remember; your project must be completed within 12 months)
Which of the following priorities does your project support? *
In addition to this, does your project help to support either of the other two health priorities; reducing health inequalities by tackling the wider determinants of health or reducing the prevalence of child or adult obesity? * No Yes
Full description of the project or initiative *
(Include key dates and milestones, along with any consultation that has been done)
Have you undertaken any form of consultation with beneficiaries for the development of the project? * No Yes
Have those who would benefit from the project been impacted by Covid-19 and if so, how? *
What will the "lasting benefit" of the project be? *
How will your project/initiative create opportunities for volunteers within the Borough? *
(This may include existing volunteers within the , as long as there are new opportunities for them to develop)
Can you confirm that your organisations activity is inclusive of any person regardless of age, sex, disability, sexual orientation, marital status, race, gender reassignment, religion or belief? * No Yes

Details of any necessary permissions, consents and/or licenses sought or received *
(if applicable)

Project Funding:

How much funding are you requesting (£)*
(Please ensure the amount requested is the same in the budget sheet you attach below)
Do you already have any match/part funding for the project? * No Yes
How are you ensuring value for money in the project or initiative? *
Please complete the Budget sheet, found here and upload it below: *
(Applications received without the supplied Budget Sheet completed, will not be considered for funding)
Please upload a recent bank statement within the last 3 months: *
(Your application cannot be assessed without this:)

Final Questions:

Are you working with children, young people or adults with care and support needs? * No Yes
Which area(s) of the Basildon Borough will your initiative benefit?
Which local client(s) group would your grant mostly benefit?
Where did you hear about this grant?

Declaration:

Please confirm you have read and accept the following? *   I confirm