Merton Health and Wellbeing Board
Promoting Health and Wellbeing in East Merton
Voluntary sector grants fund
Round 6
Application Form
Please type and answer all the questions and refer to the criteria and
guidelines throughout, as this will help you to answer the questions correctly
SECTION A: ELIGIBILITY CRITERIA
In order to be eligible for a grant, you must be able to answer yes to all the following
questions:

Will the proposal contribute to bridging the gap in health and wellbeing between
residents living in the eastern and western wards?

Will the proposal increase the health and wellbeing of families and communities
in the east of the borough?

Will the proposal benefit Merton residents living in one or more of the 10 priority
wards?

Does your proposal fit well, with one or more of the 4 themes?
Name of Organisation:
Brief description of your proposal (Maximum 25 words)
How much money are you requesting from this Fund £
(The maximum grant is £4,000 single organisations or £10,000 for partnership
bids)
Is this a partnership bid? Yes/No
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Who is the lead partner?
What was your organisation’s income in the last financial year? £
Please attach a copy of these accounts with this application
SECTION B: ABOUT YOUR ORGANISATION
Contact Details
Contact name:
Position in organisation:
Address:
Telephone:
1.
Email:
What kind of organisation are you? (highlight all that apply)
Community group/club/society
Registered charity
Charity Number:
Company limited by guarantee
Company Number:
Community Interest Company
Company Number:
Other (please specify):
2. How many people work in your organisation?
Number of Staff:
Number of Active Volunteers:
Number of Management Committee / Board members
3. When and why was your organisation started and what activities do you currently carry
out? (see guidelines)
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4. Do all staff and volunteers who have contact with vulnerable adults and/or children &
young people have a current DBS disclosure? (Please delete as applicable)
Yes / No
What other safeguarding procedures does your organisation have in place? (see
guidelines)
5. Does your organisation have a quality assurance standard? (Please delete as
applicable)
Yes / No
If yes please tell us which one/s (e.g. PQASSO, IIP, Investing in volunteers) (see
guidelines)
Expiry date:
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SECTION C: ABOUT YOUR PROPOSAL
6. List up to 4 key outputs. Please provide a detailed and specific description of what the
grant will be spent on (see guidelines)
Example: 12 weekly x one hour dance classes for up to 20 adults with obesity.
1.
2.
3.
4.
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7. How will the activities described above make a difference to the beneficiaries? Tell us
about the expected immediate and longer term benefits – the outcomes. Make them
detailed and specific as these will be used for monitoring purposes (see guidelines)
8. How does the proposal contribute to bridging the gap in health and wellbeing between
residents living in the eastern and western wards? (see guidelines)
9. Which of the theme/s does your proposal address and how? (see guidelines)
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10. What need is this proposal addressing and how have you identified this need?
(see guidelines)
11. Who will benefit from the proposal and which of the priority wards will the beneficiaries
come from? (see guidelines)
12. How will you involve your service users in the design, delivery and development of
your proposal? (see guidelines)
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13. How will people will be involved in your proposal in a voluntary capacity? (see
guidelines)
14 How will you measure the success of the proposal? (see guidelines)
SECTION E: FUNDING REQUIRED FOR THIS PROPOSAL (see guidelines)
What is the total cost of this proposal? £
Income source
Amount
Total Income
Expenditure
Amount
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Total Expenditure
If you wish to clarify any of the above information please do so here:
SECTION F: DOCUMENTS WE NEED FROM YOU
If your application is successful we may request some or all of these
documents from you – do not send them now

Latest Annual Report (if you have one)

Names and addresses of current Management Committee/Trustees or Directors

Business or Strategic Plan (if you have one)

Vulnerable Adults Policy/Child Protection Policy and confirmation that all
staff/volunteers meet the current safeguarding requirements including CRB checks

Reserves Policy

Finance Policy

Governing Document

Equality & Diversity Policy

Evidence of appropriate insurance cover
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
Your Bank account details (you will be paid by BACS)
We may also require job descriptions and staffing information and reserve the right to
request further relevant information.
If you are a new group (under 1 year old) we will require a reference from someone who
knows the work of your organisation. This may be someone from a local support agency,
LBM or another voluntary organisation.
Section G: Terms and Conditions of Grant
In submitting this application form, we
understand and agree to the following:
1.
c.
If we are awarded a grant, we will use it
for exactly the purpose set out in this
application, unless a specific condition
has been attached to the award.
2.
We will not make any major changes to
the proposal without first receiving the
Health and Wellbeing Board’s
agreement in writing.
3.
We will not use the grant to order or buy
any goods before we receive the grant
offer letter.
4.
We will not use the grant to pay for any
item which has been funded under
another grants programme.
5.
We will take all reasonable steps to:
deliver value for money and use
sound financial procedures;
d. share information that will contribute
to the understanding of future client
needs.
6.
We will acknowledge the Merton
Partnership’s grant in our annual report
and in all printed materials as
appropriate. We will supply copies of
these documents to MVSC if requested.
7.
We will have a bank or building society
account in the name of our group (or, if
applying as a consortium or partnership,
in the name of the accountable group).
We confirm that all cheques or
withdrawals from this account require at
least two signatories.
8.
We will keep all financial records and
accounts, including receipts for items
bought with the grant, for at least six
years. We will provide sufficient
insurance cover to meet potential
liabilities and produce evidence of
payment of the current premiums and
note that MVSC may request us to
a. offer equality of access to our
services;
b. provide a safe, healthy and
supportive environment which
meets the needs of the local
community;
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provide copies of our employer’s
liability, public liability and buildings
insurance policies.
9.
10.
whole or in part, in the following
circumstances:
a. if we fail to keep to our funding
agreement in any way;
We will allow the Merton Partnership
and the Health and Wellbeing Board to
use our name in their publicity
materials. We will inform MVSC of any
situation where confidentiality is a
particular issue.
b. if the application form was
completed dishonestly or the
supporting documents gave false or
misleading information;
c.
We will send MVSC all relevant
monitoring information at the end of the
project and meet all monitoring and
financial requirements as requested
during the life of the grant, subject to
Data Protection regulations.
11.
We will allow MVSC to visit us to see
the work funded by this grant.
12.
We note that the Health and Wellbeing
Board will ask us to repay the grant, in
if any member of our governing
body, staff or volunteers acts
dishonestly or negligently in respect
of this grant;
d. if we close down or become
insolvent.
13.
These terms and conditions will apply
until we have spent the grant and
submitted all related documentation.
This form should be signed by a senior member of your organisation’s Trustee Board or
Management Committee, e.g. the Chair, Vice-Chair, Treasurer or Secretary. This must be
a different person to the contact named on page 1.
I confirm that I am authorised to sign this application form on behalf of our group
and that the information we have provided in the form is true. I confirm that I have
read and understood the above terms and conditions and, if our application is
successful, we agree to comply with them.
Name (please print):
Position in organisation:
Signature:
Date:
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Please return this application form by email or post to:
Application deadline: 12pm (Midday) Monday 21st December
2015
Send a signed copy within 5 days of the above deadline to:
Beau Fadahunsi
Merton Voluntary Service Council
The Vestry Hall
London Road
Mitcham CR4 3UD
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