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