Canterbury Social Support Fund
INFORMATION ABOUT YOUR ORGANISATION
1) CONT ACT DET AILS
What is your organisation’s name?
What is its legal name?
W HAT IS YOUR ORGANISATION’S ADDRESS?
POSTAL ADDRESS:
PHYSICAL ADDRESS:
Postcodes can be accessed from www.nzpost.co.nz/postcode
Street:
Street:
City/Town:
City/Town:
Postcode:
Postcode:
W HAT ARE YOUR ORGANISATION’S CONTACT DETAILS?
Phone:
Email:
Fax:
Website:
W HO IS THE MAIN CONTACT FOR THIS APPLICATION?
Name:
Position:
Daytime phone:
Email:
Alternate phone:
If your organisation currently receives funding from central or local government, please provide the name of
the agency and their funding contact person. If not, then provide details of two other funders or referees.
I am authorised to submit this document on behalf of my organisation. I understand this is an
application only and does not guarantee funding will be granted.
2) ORG ANIS ATION DET AILS
A) ORGANISATIONAL STATUS
Your organisational legal status:
Current company registration number / Charities Commission number:
GST registration number:
B) IN WHICH LOCATION WILL YOUR ORGANISATION BE DELIVERING THE SERVICES?
Please indicate:
Christchurch City Council – please specify town/suburb:
Waimakariri District Council – please specify town/suburb:
Selwyn District Council – please specify town/suburb:
Other – please specify:
3) WHICH VULNER ABLE POPULATIO N GROUPS WILL THIS
APPLIC ATION CONTRIBU TE TO?
Please indicate the relevant population groups:
Children and youth
Older people
Disabled people
Single parents with dependents
People with pre-existing/concurrent psychiatric illness
People who have experienced previous traumatic events or stress (eg family violence victims)
Lower socio-economic status
Maori
Pacifica
Refugees and migrants
People with housing related needs
People under financial stress
People living in worst hit areas
Those who have already been significantly affected by the Canterbury earthquakes
Those who have experienced significant injuries
Family/friends/colleagues of those who have died
Canterbury Social Support Fund
Ministry of Social Development – Family and Community Services [September 2012]
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4) WH AT IS THIS APPL IC ATION PRIM ARILY FO R?
Please tick only one:
Individual and Whanau Recovery and Wellbeing
or
The Building of Community Resilience
5) DESCRIPTION OF ACTIV ITY OR PROJECT
Insert description: (Word limit 500)
6) PROJECT GOAL AND BENEFITS
Insert description: (Word limit 500)
7) WH AT EVIDENCE IS AV AIL AB LE TO SUPPORT TH AT THE
SOCI AL NEED HAS ARIS EN AS A RESULT OF TH E
C ANTERBURY EARTHQU AK ES?
Insert description: (Word limit 350)
8) WH AT EVIDENCE IS AV AIL AB LE TO SHOW TH AT THE
COMMUNITY CONCERNED SUPPORTS THE NEED FOR THIS
WORK?
Insert description: (Word limit 350)
Canterbury Social Support Fund
Ministry of Social Development – Family and Community Services [September 2012]
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9) HOW WILL THE PROJECT MEET THE IDENTIFIED NEED?
Insert explanation: (Word limit 500)
10) DESCRIBE THE EX PECTED RESULTS / SOC I AL OUTCOMES,
AND HOW THESE WILL BE ME AS URED
Insert description and explanation: (Word limit 500)
11) HOW M ANY INDIVI DU ALS / FAM ILIES WIL L THIS FUNDING
ASSIST?
Insert number and descriptor:
12) FUNDING AMOUNT REQUESTED
Insert amount of funding requested:
13) BUDGET BRE AKDOW N
Provide a budget detailing how you propose to spend the funding for which you are applying:
14) ST ART AND END D ATES
Provide the start and end dates for the project:
Canterbury Social Support Fund
Ministry of Social Development – Family and Community Services [September 2012]
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15) PROVIDE DET AILS OF ANY OTHER GR ANTS OR FUNDS
RECEIVED OR APPLIED FOR IN REL ATION TO T HIS PROJECT
Insert details:
16) GIVEN TH AT THIS FUNDING IS ONE-OFF, HOW DOES YOUR
ORG ANIS ATION PROPOSE TO FUND THIS INITI ATIVE IN AN
ONGOING W AY, OR WILL IT BE SELF SUST AININ G OR TIME
LIMITED?
Insert explanation: (Word limit 350)
17) HOW WILL YOU CO LL ABOR ATE WITH OTHER
ORG ANIS ATIONS WORKIN G WITHIN THE COMMUNI TY?
Insert explanation: (Word limit 350)
18) HOW DOES YOUR O RG ANISATION WORK WIT H
VOLUNTEERS?
Insert explanation: (Word limit 350)
Canterbury Social Support Fund
Ministry of Social Development – Family and Community Services [September 2012]
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ACKNOWLEDGEMENT
In submitting this application, I:
•
acknowledge that the grant is “one-off” funding to respond to pressures associated with the Canterbury
earthquakes
•
confirm that this organisation is financially viable, and has effective governance and management
•
agree to actively participate in the co-ordinated response supported by FACS/MSD
•
agree to sharing of information relating to this agreement
•
agree to participate in a community accountability exercise if requested.
In the event that the services are not required or unable to be delivered, we will contact Family and
Community Services as soon as this becomes apparent.
I am authorised to make this application on behalf of my organisation.
Name:
Designation:
Date:
PLEASE ENSURE YOU HAVE ACTIONED THE FOLLOWING:

Completed all questions on the application form.

Included a copy of your organisation’s latest independently audited financial accounts, or
similar.

E-mailed your completed form to:
eqfund@familyservices.govt.nz
Alternatively, you can mail your completed application form to:
Family and Community Services
PO Box 20208
Christchurch
FOR MORE INFORMATION OR ASSISTANCE COMPLETING THIS APPLICATION:

Contact your Ministry of Social Development funding advisor

Call 0800 777 100

E-mail queries to eqfund@familyservices.govt.nz

Visit www.familyservices.govt.nz
Canterbury Social Support Fund
Ministry of Social Development – Family and Community Services [September 2012]
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