Memory Activity and Support Groups Grant Application Form Memory Activity and Support Group Grant Application Step 1 of 12 8% About this form Save and Continue Feature Please note, this application form can be saved partway through. Please click the Save and Continue Later link at the bottom of any page. You will be asked to supply your email address and you will be emailed a link to your application form so that you can continue to complete it at a later date. All questions marked with an asterix* require an answer and cannot be skipped. You will need to complete all questions with an asterix* before moving onto the next page. If you are not sure how to complete this form or need help with any other queries relating to the grant, please call us on 01736 756655 or email Grants Data Protection CRCC complies with the EU General Data Protection Regulations and the Data Protection Act 2018. By sending this form to us, you agree that we can securely store your personal information on our database or in the form of paper records, and that we can use your information in order to provide a service to you as part of the Wellbeing Community Grants Programme. We will only collect and process information in accordance with the legal basis for the service you are receiving. We will not sell your information or share it with any other organisations. We will not keep this information longer than necessary (this is normally for two years following the end of the contract year); it will then be securely destroyed. Our full Privacy Statement is available on request and can be viewed on our website at www.cornwallrcc.org.uk/policies-procedures If you wish to withdraw your consent, or if you wish to see a copy of the information we hold about you, please forward your request to the Grants and Compliance Lead on 07715 799395 or email dataadmin@cornwallrcc.org.uk Please note, for the benefit of this grant, a formal group is one that has a group name, meets regularly throughout the year and has a bank account in the group's name. An informal group is where individual carer friends simply wish to do something together.Contact InformationHave you read and understood the Terms and Conditions that accompany this application form?* Yes No - please get in touch with us with any queries before continuing Name of group* Name of organisation (if applicable) Your name* Your position in the group or organisation* Contact address and postcode*Daytime telephone number* Email* Please tick to confirm your group is not commissioned by Cornwall Council, NHS Kernow or IoS Council* Not commissioned For formal groups, please tick to confirm that you have Public Liability Insurance for activities & meetings*This is a requirement of funding. For new groups: this grant can fund insurance so please include this in your costings. Yes we have PLI No but we are requesting funds for this in this application Not applicable Does your group have a Safeguarding Vulnerable Adults policy?*If no, we may need to contact you to discuss how you are able to support vulnerable people and to help you in creating a policy for your group. Yes we have a SVA policy No we do not have a SVA policy About your groupAre you a new group?* Yes No How many members with memory loss attend the group?*How many carers/friends/family attend your group (if applicable)? How many volunteers (if applicable)? Please tell us how your group is complying with government rules for Covid-19 around social distancing, etc.*Group members are expected to be involved in the planning of group activities and decisions about how the grant might be spent. Please explain how your group involves its members.*Formal groups are required to have a steering group or committee (e.g. Treasurer or Secretary)that oversees the grant spend. Please tell us about these people hereNameRole Please tick if you would like us to send you information on either of these services>b>Cornwall Carers Service can provide carers with advice and guidance, advocacy, the opportunity to meet with a Carer Wellbeing Coordinator and information about benefits Inclusion Matters can provide information and advice to increase well-being and connection to your community. Cornwall Carers Service Inclusion Matters About your funding requestHas your group received this grant from us before?* Yes No Have you sent us your feedback report and relevant receipts?* Yes No - You can still apply but you will need to send these to us before we can award a further grant When was the last time you had a grant from us? Month/ year* How much money are you applying for?*Max £1000 per application. New groups will receive a start-up grant of £500, then can apply for the remaining funds later (up to £500). Formal groups (with a group bank account and a committee) may also apply for an additional amount of up to £500 if they are purchasing internet-enabled devices to be loaned out to group members. What would you like funding for?* General group running costs (e.g. room hire, insurance, etc Activity costs Start-up costs (£500 max) Tablets / mobile hub costs (additional £500 permitted for formal groups) Please summarise what you would like funding for*How will these items/ activities support people with dementia?*If you are applying for tablets/ mobile hubs, please answer the 4 questions belowTech* We are applying for tablet/ mobile costs We are *not* applying for tablet/mobile hub costs Please confirm that the devices will be owned by the group but will be loaned out to members who need them to connect with other members online* Yes the devices will be owned by the group Please confirm that members will be supported to connect online safely* Yes we will ensure members understand internet safety Please explain why other sources of funding for these items are not available or applicable*Please explain how members will be supported to increase their skills and independence to connect online* Where possible, please provide on the following page a detailed list of costs that you would like the grant to fund below. Please submit evidence of these costs with your application. We need to know how you worked out your costs so please send us quotes, website addresses, previous invoices or receipts, etc. Please check the Terms and Conditions for details of what the grant can and cannot be used for. Costings*Please list each item or activity on separate rows. To add extra rows, click on the + symbol at the end of the row you've just completed. Examples: ITEM - HOW MANY - COST PER ITEM - TOTAL COST Room hire - 24 sessions - £15 per week - £360 Group outing to Trebah Gardens - 30 people - £8pp - £240 Music workshops, Music for All – 2 workshops - £50 per session - £100 Pottery equipment: clay, tools, paint - 25 people - N/A - £130 total Name of item/ activityHow many? e.g. 12 peopleCost per person/ session/itemTotal cost Please use this box to detail any web links that evidence where you got your costings from.If you wish to upload evidence of costs please do so here.You can upload multiple documents if you need to Drop files here or Select files Max. file size: 64 MB. Your bank details If your application is successful, payment will be made directly into your group’s bank account. The account must be in the group’s name and have at least two signatories. We may agree to pay funds instead to a sponsoring organisation providing we have a Financial Declaration from that organisation’s Finance Officer or similar. Please call us on 01736 756655 for a copy of the form. bank account* We have a group bank account An organisation will hold funds on our behalf Name of bank/ building society* Account name* Account number* Sort code* Professional referee All groups applying to the grant must provide a reference from a local professional or local recognised organisation who can vouch for/endorse the aims, objectives and support mechanisms of the group. Please ask your referee to write a brief reference which you can then submit with your application. You will need to send the reference to us, ideally with your application, before the application deadline. Please send the reference to us by email to grants@cornwallrcc.org.uk or upload your reference below. It is your responsibility to ensure we receive your reference before the application deadline. Please tick to confirm that your reference is accompanying this application form or is being sent separately by the referee* My reference is uploaded below My reference is being sent separately If you wish to upload your reference, please do so hereMax. file size: 64 MB. Declaration and agreement*Please tick all boxes to indicate your agreement I agree to the Terms and Conditions of the Memory Activity and Support Groups Grant as set out in the guidelines that accompany this form. We will only use the grant for the items or activities stated in our application or we must get permission from CRCC first to make any changes. I understand that if CRCC is not satisfied with how the money has been used we may be asked to repay some or all of the grant. I am submitting evidence of the costings relating to the items/activity that we are requesting a grant for, e.g. quotes or website addresses, etc. I understand that this grant cannot be used for items/activities already paid for. I agree to complete a feedback report on how the grant was spent and how it has helped the group, and agree to send in all relevant receipts. Feedback reports must be sent back within 3 months of the final activity or by 30 June 2022, whichever is sooner, using the template provided I understand that if I leave the group, I will ensure someone else in the group takes responsibility for the grant and will inform CRCC of this I have read the Data Protection statement in the Terms and Conditions and agree to how CRCC will hold/use my details. I confirm that the information provided in this application is true and accurate to the best of my knowledge. Would you like to join our mailing list?*We occasionally send out emails to advise people of events and services that may be of interest to them, including updates on grant programmes. You can choose from the list below which type of emails you would be interested in receiving. You can unsubscribe at any time using the link at the bottom of each email. We will not share your name and email address with any other party. Click here to read our Privacy Statement Yes please No thank you Please select your mailing list preferences*Please tick ALL that apply Grants - we will only contact you with information about our grant programmes Other CRCC info - receive occasional emails about other services we offer About other approved services and organisations Next steps You should automatically receive a copy of this form by email after you click SUBMIT. Please retain this copy as you may need to refer to your application form if we have any queries, plus you will need to refer to it when completing a feedback report. Additional information If you need to call us, our number is: 01736 756655 Our email address is: grants@cornwallrcc.org.uk
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