Grant application form

Section 1 – Organisation

Name of your organisation:

Address:

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Telephone number:

Email:

Website:

Charity number (if applicable):

Main contact person:

First Last

Job title:

Telephone number:

Email:

What type of organisation are you?

Registered charity

Local authority

University

Road Safety Partnership

Other

About your organisation

What does your organisation do? (50 words)

Please provide a short summary of the project/activity you are seeking a grant for? (100 words)

Section 2 – Your Project/Activity

Project Title:

Project start date:

Project end date:

Outline the aims and objectives of your project.

How have you identified the need for this project? Please include any data, research or scoping work that you have carried out, or that others have carried out, that supports the evidence of need:

Please provide details of what you will deliver, including how you will deliver it, who will deliver it and timescales involved.

What impact or difference will your project make to road safety?

How will you monitor and evaluate the outcome of your project?

How will the evaluation and project learning be shared/disseminated more widely to those who could benefit from the findings?

How will you sustain the benefits of the project after the project ends?

Section 3 – Project Budget

What is the overall cost of your project

How much are you seeking from the GEM Road Safety Charity?

Have you applied for other sources of funding for this project?

Yes

If yes, please sate the organisation, the amount and if this funding is secured, or when you expect to hear about the funding is you are still awaiting a decision:

Breakdown of the total budget:

Fixed amount

Range

Fixed amount

Range

Please give details of any contract, agreement or understanding with a third party concerning any exclusive condition, restriction, requirement, product placement or promotion regarding any aspect of this grant application:

Section 4 – Bank Details

In the event that a grant is awarded, we will make payment via BACS directly to your organisation’s bank account. Please complete the details below.

Bank name:

Account name:

Sort code:

Account number:

Section 5 – Supporting Documents

Please provide us with your supporting documents by attaching them to this application. If this is not possible then, please e-mail them separately.

Copy of one bank statement from the past three months. If relevant to your project, a copy of your organisation’s Safeguarding policy (child/vulnerable adult protection policy).

Max. file size: 16 MB.

If your project involves working with children or vulnerable people, please confirm that your staff / volunteers have the appropriate DBS checks in place.

I confirm

Terms & Conditions

The organisation, if successful, shall use the grant funding only for the purposes as set out in the original application and the Letter of Offer.
The organisation shall acknowledge GEM Road Safety Charity’s (The Charity) contribution to the project in all publicity and marketing (including on social media) and will provide The Charity with a copy of all articles published in the media.
The funding will be spent by the organisation with due account to efficiency, value for money and effectiveness.
The organisation will inform The Charity as soon as possible should it not be able to spend the grant funding on the purposes for which it was awarded. In such circumstances the grant amount is to be refunded to the Charity.
The organisation will inform The Charity as soon as possible if the full project will not be delivered due to a failure to secure any additional funding required. In such circumstances any remaining monies, or the full grant, shall be refunded to the Charity.
The organisation will, within two months of the completion of the project for which grant funding was awarded, submit a short monitoring report or other monitoring data as stated in the application or as otherwise agreed with The Charity.
The Charity can request repayment of all or some of the grant funding in the event of the organisation’s failure to meet these Terms and Conditions.
By signing the declaration, the organisation is accepting that The Charity can use details of the project, including images provided, for publicity and marketing purposes. If there is a safeguarding or other significant reason why this is not appropriate it must be agreed by The Charity prior to acceptance of the grant.
The Charity accepts no responsibility, financial or otherwise, for expenditure or liabilities arising out of the work of the organisation. The organisation fully indemnifies The Charity against all claims, actions and demands howsoever arising. The organisation confirms that any insurances, permissions or legalities required will be obtained or complied with respectively for the duration of the project.

Declaration