Community Wellbeing Grants Program Application Form

Please complete the application form below to apply for a 2021 Community Wellbeing and Engagement Grant. Before you apply for a Grant, please click here to review and confirm your group or organisation is eligible. Applications close 5:00pm AEDT on Monday, 25 January 2021

Community Wellbeing Grant Program

General Information
Organisation/Group:*
Organisation website:
Key Contact Name:*
First Last
Contact Email:*
Contact Phone Number:*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
ABN*
Account name*
Details for Electronic Funds Transfer (to be used if successful)
BSB and Account Number*
Your Activity or Event
Acivity/Event Name:*
Please provide the intended name of your activity or event. You can change this via the registration process later if need be.
Activity/Event Focus*
- Mental Health
- Alcohol and Other Drugs
- Both
Activity/Event Description:*
Please provide a brief description of your proposed activity or event (200 word limit)
Activity/Event Goals:*
Describe your activity or event objectives/goals and how you plan to achieve them (200 word limit)
Activity/Event Date (if applicable):
Please note: activities or events must be held between the 10 February to 30 June 2021.
Date Format: DD slash MM slash YYYY
Event End Date (if applicable):
(If you're event is planned to run over multiple days, please enter the end date)
Date Format: DD slash MM slash YYYY
Activity/Event Start Time (if applicable):

: HH

MM
Activity/Event End Time (if applicable):

: HH

MM
Activity/Event Location (if applicable):
How many people do you expect to attend your activity/event?*
Partnerships:
If you intend to partner with other organisations for this activity or event, please provide the organisation’s name/s and outline their involvement (200 word limit)
Event Promotion*
How do you plan to promote your activity or event to ensure its success, including targeting community members not already engaged with or linked to the community? (100 word limit)
Education and Help-seeking (if applicable)
Please describe how your event or activity will educate participants about protective wellbeing strategies and encourage help seeking behaviours. To access evidence-based resources please refer to the Community Wellbeing Grant Program webpage (200 Word Limit )
Activity/Event Target Audience (if applicable)
Please describe how your activity or event demonstrates proactive engagement with particular segments of the population and/or people living in isolated geographical areas (i.e. culturally and linguistically diverse, Tasmanian Aboriginal people, lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual and allied people (LGBTQIA+)).
New Audience Engagement (if applicable)
Describe how you plan to engage with new audiences (eg. through a new event or activity, through an existing event or activity but with new participants, or an event or activity that will be different to those within the local area) AND/OR describe how the activity or event reaches people who are not connected to the broader community
Participant Wellbeing*
Describe what actions you will put in place during the activity or event to safeguard the wellbeing of participants (e.g. use of safe and respectful language, access to emotional support)
COVID-19 Compliance*
Outline what steps you plan to take to ensure your activity or event is COVID safe
Event Budget*
Item Cost Funding Source Purpose
Total Budget*
Grant Value*
Supporting Evidence
You may upload additional supporting evidence, however this is optional only and is not considered part of the selection/assessment criteria.
Drop files here or
Application Compliance and Checklist
Please read and tick all boxes to show you understand and agree to these terms.
I acknowledge that if successful in receiving a grant I MUST display the #Checkin logo and with the following acknowledgement wording on all collateral: “This grant program is supported by Primary Health Tasmania (Tasmania PHN) under the Australian Government’s primary health networks program” in the promotion of my activity/event*
I agree to use the above logo and acknowledgement.
Grant Evaluation and Acquittal*
Are you willing to complete the official Acquittal Report after your activity/event? (this will be sent to you immediately should your application be successful)
Public Liability Insurance*
Will your activity/events be covered by Public Liability Insurance?
- Yes
- No
Proof of Insurance
If yes, please upload your insurance cover
I have completed all sections of the application form*
Yes
I have included a budget and the amount I am applying for*
Yes
I have read the latest requirements and I ensure the activity or event complies with the minimum COVID-19 requirements for public gathering.*
I agree
The latest Tasmanian Government requirements
I acknowledge that if I am successful in receiving a Community Wellbeing Grant I am prepared to have my activity/event advertised upon the #Checkin Events page unless otherwise agreed upon with the Mental Health Council of Tasmania*
I agree
I acknowledge that if I am successful in receiving a Community Wellbeing and Engagement grant I am prepared to stage my event or activity during 10 February to 30 June 2021 unless otherwise agreed upon with the Mental Health Council of Tasmania*
I agree
I acknowledge that if I am successful in obtaining a grant it has been awarded on the merit of this application therefore if there are any changes to my event following submission of this application OR receipt of a grant I will inform the Mental Health Council of Tasmania of these changes as a matter of priority*
I agree
I acknowledge that where there are significant changes to my activity/event application the selection panel have the right to review allocation of grant funding based on those changes*
I agree
I acknowledge that the selection panel have the right to consider equitable distribution of funds across the state in their assessment of grant applications*
I agree
I acknowledge that the selection panel may offer partial funding and/or attach conditions to the allocation of grant funding*
I agree
I acknowledge that if my application is successful I will nominate ONE key contact from the activity/event to liaise with the Mental Health Council of Tasmania in relation to activity/event matters*
I agree
I acknowledge that if successful I will be required to provide evidence of appropriate acquittal of funding*
I agree
I acknowledge that if successful I will be required to evaluate my activity/event and provide a summary of the evaluation to Mental Health Council of Tasmania by no later than COB on the 30th July 2021*
I agree
Submitting the Grant Application
By submitting your application, your organisation is agreeing to the following terms:

• Applications that are not authorised and submitted by a representative of their organisation will be deemed ineligible.
• Applications which are not successful will be notified via email and can be contacted for further information upon request.
• All applications will be assessed by a selection panel comprising of a representative from the Mental Health Council of Tasmania, Alcohol, Tabacco and Other Drugs Council of Tasmania, Primary Health Tasmania and other appropriate community event representatives.

I agree to the above conditions of the application process and can assert that all information provided in this application is true and accurate at the time of submitting:
Name of Authorised Person*
Organisation/Group:*
Date:*
Date Format: DD slash MM slash YYYY
*Please be advised that MHCT will include all grant applicants on the MHCT mailing list to receive updates and information on Mental Health Week

Save and Continue Later

Item	Cost	Funding Source	Purpose

Just checking –do you, or someone you care about, need help with your mental health?

Community Wellbeing Grant Program

General Information

Your Activity or Event

Application Compliance and Checklist

Submitting the Grant Application