Application form for
Chorley District Early
Support & Intervention
Small Grants Fund
This is to benefit children,young
people, and families living in the
community of Chorley district
Supported by
Chorley Children and Young People's Trust Partnership
Early Support & Intervention Fund
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SECTION A: ABOUT YOU
1. Name of Group
2. Name of main contact
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Date of Birth (if a young person)
3. Address of main contact
4. Contact Number and email address
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In which area of Chorley, Lancashire is your group based - or the activity based if it's
not running at your base e.g.
5. Tell us a bit about your group: When do you meet? How often and where?
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Contact (including postcode)
6. The number of young people, children or families involved in making your group
application
* For young people with additional needs or a disability
5-11
Total numbers
11-13
Male
13-16yrs
Female
Parents/carers
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SECTION B: ABOUT YOUR PROJECT
7. Are you applying as a group
Or as an individual
(Please Tick)
What is your project? Please describe this in detail.
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8. How will the project benefit the children, young people, and families in the
community?
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9. How are/will children, young people and their families be involved in developing
and running the project?
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10. Have you consulted children, young people, and families, if so how?
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Can
young people currently access the service? If yes why is more needed?
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11. Can children, young people or families currently access this service? If so why
is more needed?
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12. Specify which group of children, young people or families will this project benefit
(please state numbers of beneficiaries)
Children &Young people with disabilities
Young Carers
Young people leaving care
Black/minority ethnic groups
Looked after children + young people
Volunteers
please also state how many hours?
Lesbian/gay/bisexual/
transgender young people
Children &Young people from travelling
communities
Youth refugees
Children & Young people from
disadvantaged areas
hrs
Youth Offenders
Teenage parents
Parents/carers of children & young people
12. How many young people will benefit from this project if you are successful?
5-11’s
Total Numbers:
11-13 years
13-16 years
Male
Female
13. Please state how many young people are from each area of the district?
Clayton-le-Woods
Coppull
Croston
Cuerden
Eccleston
Euxton
Heapey
Heath Charnock
Heskin
Hoghton
Mawdesley
Rivington
Ulnes Walton
Wheelton
Whittle-le-Woods
Withnell
Other please state
Number and area
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14. Please tell us which of the Early Support & Intervention Fund priorities your
project fits into (you can choose more than one). Please tick your chosen priority and
fill in relevant boxes. Please relate this to your community benefit.
a) Things to do and Places to go
Select from the outcome menu which particular outcome this project contributes to
(you can pick more than one).
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Improving the % of young people participating in positive activities in their
spare time
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Improving the % of families participating in positive activities together.
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Improving the % of parents and young people volunteering in their local
community.
How will this outcome be achieved?
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b) Identify and respond to the emotional and
social wellbeing of children and young people
How will this outcome be achieved?
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c) Prevention & Early Intervention Support for
Children, Young People and Families
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Select from the outcome menu which particular outcome this project
contributes to (you can pick more than one).
% of parents/carers, children, and young people reporting improvement in
family life
% of parents/carers, children and young people accessing the support they
need to maintain healthy lifestyles and meet their emotional, physical and
well being needs
% of children, young people and families reporting less social isolation
How will this outcome be achieved?
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d) Reducing Young People Not in Education, Employment or
Training
Select from the outcome menu which particular outcome this project contributes
to (you can pick more than one).
 % of young people accessing employment, training and education
opportunities
 % of young people accessing volunteering opportunities in their local
community
 % of young people participating in positive activities in their spare time
How will this outcome be achieved?
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15. Any other comments about how your project supports one of
the 4 Early Support and intervention priority theme areas for
Chorley district?
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SECTION C: PROJECT COSTS
16. Project Breakdown:
A. You must include a breakdown of what you plan to spend the money on. Fill these
details in on the form below. (Continue on an additional sheet if necessary)
B. You must provide accurate costs for everything you list below. We need to see evidence
of these costs. These could be quotes, print outs of prices from the internet, etc. Please
attach these to you form. You must at least show separate categories for staffing and
management costs and add any other specific categories as appropriate according to the
needs of your project.
PLEASE NOTE ONLY PART OF YOUR APPLICATION MAY BE FUNDED
ITEM
Cost
Staffing
Management
TOTAL
£
IMPORTANT: We will not award money If it is unclear or if there is no evidence for
exactly how much your project will cost.
Have you applied for match funding? YES
NO
If yes then please tell us how much you have applied for and to who?
If your application is successful, what date will the money be spent by?
Application Total (This is the total amount you wish to apply for)
£ ____________
Project Total
(This is the total amount that your project will cost) £ ____________
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SECTION D:YOUR SUPPORT
(To be filled in by an adult e.g. parent/carer/youth worker/teacher
if you are under 18 years)
17. As an adult you will be legally responsible for this project and will be
accountable. Please ensure you read though the application carefully before you
sign.
Name
Contact Number
Address (including postcode)
Email Address
What is your relationship to the group?
SECTION E: SIGNATURES
18. Please check through your form thoroughly and make sure you have filled
everything in. If anything is left incomplete we will not assess it and will return it to
you.
If you are happy with all the information you have included and can verify it as being true
please sign below. If you are successful and accept the grant and responsibility for it you
will be asked to sign a service level agreement which outlines the monitoring arrangements
for this project.
Young person’s signature
Date
Adult support signature
Date
OFFICE USE ONLY;
Date received by EIDO
Date passed onto Senior EIDO
Date grant panel met to discuss
Date awarded funding
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SECTION F: WHAT NEXT?
PLEASE ENSURE THAT THE APPLICATION FORM IS COMPLETED IN FULL AS ANY
INCOMPLETE FORMS WILL BE RETURNED.
Email your completed form and any supporting evidence to BY MID-DAY
on Friday 7th June 2013:
[email protected]
Ruksana Mulla
Early Support & Intervention Development Officer (South Ribble)
Lancashire County Council
Mobile: 07827 232 536
Make sure you keep a copy of the completed form for your records.
When we receive your completed application form a member of staff will then check it to
see:
• If all the information on the application form has been completed
• If all the relevant information is attached
• If your project seems well thought through and planned
We will photocopy it and pass it on for consideration, to the Awarding Panel who comprises
of Senior Managers of the Children's Trust and the Senior Early Intervention Development
Officer.
They may contact you for more information. The form will then be assessed by the Panel
who will score it and assess it against their guidance and criteria. You will be informed by
post if you are successful by Wednesday 12th June 2013.
You then have a maximum of 2 weeks to complete the paperwork and claim the
money, before you are able to start your project.
You will be asked to give us more information about how the project went and who
benefited. Details of the information you will be expected to provide will be in the Service
Level Agreement. Any advertising must be agreed with the Early Support & Intervention
Development Officer and you must state that funding has been provided from the Early
Support & Intervention Fund, Lancashire County Council which supports the Early Support
& Intervention priorities for the district set by the South Ribble Children's Trust Board.
If you have any questions please contact:
Ruksana Mulla: 07827 232 536 or e-mail :[email protected]
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