Wellbeing and Resilience Grants Application Form

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*

Account Number*

Your Activity or Event

Training/Activity/Event Name:*

Please provide the intended name of your training, activity or event. You can change this later if need be.

Training/Activity/Event Description:*

Please provide a brief description of your proposed training, activity or event (200 word limit)

Training/Activity/Event Goals:*

Describe your training, activity or event objectives/goals and how you plan to achieve them (200 word limit)

Training/Activity/Event Date (if applicable):

Training/Activity End Date (if applicable):

(If your event is planned to run over multiple days, please enter the end date)

Training/Activity/Event Start Time (if applicable):

: HH

MM

Training/Activity/Event End Time (if applicable):

: HH

MM

Training/Activity/Event Location (if applicable):

How many people do you expect to attend your training/activity/event?*

Partnerships:

If you intend to partner with other organisations for this training, activity or event, please provide the organisation’s name/s and outline their involvement (200 word limit)

Promotion*

How do you plan to promote your training, activity or event to ensure its success, including targeting community members not already engaged with or linked to the community? (100 word limit)

Alignment with the National Disaster and Wellbeing Framework*

Describe how you plan to fit the proposed activity within the lower levels of response in the National Disaster and Wellbeing Framework (points 3.1.1 prevention and preparedness 3.1.3 support targeting communities and families), found on the Wellbeing and Resilience Grant Program webpage

Participant Wellbeing*

Describe what actions you will put in place during the training, activity or event to safeguard the wellbeing of participants (e.g. use of safe and respectful language, access to emotional support)

Training/Activity Budget*

Add more rows as required

Item	Cost	Funding Source	Purpose

Total Budget*

Grant Value requested*

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 use the following statement in my promotions: ‘This initiative is supported by funding from Primary Health Tasmania (Tasmania PHN) through the Australian Government’s Primary Health Networks Program.’*

I agree to use the above acknowledgement.

Are you willing to complete the official Acquittal Report after your training/activity/event? (This will be sent to you immediately should your application be successful)*

I agree

Public Liability Insurance*

Will your training/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 acknowledge that if I am successful in receiving a Wellbeing and Resilience Grant I must provide training/event details and any promotional materials to the Mental Health Council of Tasmania*

I agree

I acknowledge that if I am successful in receiving a Wellbeing and Resilience Grant I must stage my activity by 30 June 2024.*

I agree

I acknowledge that if I am successful in receiving a Wellbeing and Resilience Grant I must expend my funds by 30 May 2024.*

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 training/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 training/activity/event and provide a summary of the evaluation to Mental Health Council of Tasmania by no later than COB on the 30th June 2024*

I agree

I have read all sections of the Wellbeing and Resilience Grant Program webpage [Eligibility; Selection Criteria; Terms and Conditions; Other requirements and considerations; Resources]*

I have read all sections of the Wellbeing and Resilience Grant Program webpage

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, Primary Health Tasmania and other appropriate community 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:*

*Please be advised that MHCT will include all grant applicants on the MHCT mailing list to receive updates and information on the Wellbeing and Resilience Grants

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

Wellbeing and Resilience Grant Program Application Form

General Information

Your Activity or Event

Application Compliance and Checklist

Submitting the Grant Application