JBF Office Only:
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THE JACK BROCKHOFF FOUNDATION
CHILDREN & YOUTH GRANT APPLICATION
PART A
YOUR ORGANISATION – Address, Contact Details and Financial Matters
Name of Organisation
(as per ATO endorsements)
..............................................................................................................
ABN/ACN
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Web site address
……………………………………………………………………………….
Your Organisation’s Purpose
……………………………………………………………………………….
(or stated “Mission”)
……………………………………………………………………………….
Street Address
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...................................................................................P/C.....................
Postal Address
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if different from above
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...................................................................................P/C.....................
Contact Person (for this application)
Mr/ Ms/ Mrs/ Dr/ Prof/ Sr/ Fth....................................................................
Position/Title …………………................................................................
Telephone (Office) …………...................................................................
Mobile …………................................................................
Email ………………………... ...............................................................
(for acknowledgment and subsequent notification regarding this application)
Program/Project Manager
(only if different to the Contact Person named above)
Does your organisation have a professional
fundraiser who is completing this application?
Date of latest audited Financial Statements /
Annual Report
(please provide a copy with your Grant Application)
Total of last year’s revenue/income
Amount and percentage of total revenue
received from Government sources
(include income from Local, State and Federal Govt.)
Amount and percentage of total revenue
received from philanthropic sources
(grants from trusts and foundations)
Total forecasted budgeted expenditure
current Financial Year
Total budgeted cost of all of your Organisation’s planned
programs this financial year
YES ☐ NO ☐
...............................................
(month/year)
$
............................
$
............................
.................
%
$
............................
.................
%
$
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The Jack Brockhoff Foundation
Children and Youth
2014
THE JACK BROCKHOFF FOUNDATION
CHILDREN & YOUTH GRANT APPLICATION
PART B
YOUR ORGANISATION – History, Purpose, Activities and Staff
Your Organisation’s background – include when established, by whom, locational boundaries of activity/client servicing, etc. (50 words)
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Characteristics of the population or community served – include demographics such as age, geographic location, number of people
assisted annually, specialist needs group, etc. (20 words)
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Provide at least one example of a successful project, program or activity your Organisation has conducted within the last 12
months – include numbers of people/clients assisted/benefitted if appropriate, other communities engaged, etc. (30 words)
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Briefly describe two of the most significant accomplishments of your Organisation within the last five years for the benefit of
the population or community you serve and the month and year they were achieved (30 words)
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Your Organisation’s Management & Staff
Number of Directors …………………………
Are they remunerated (paid)?
YES ☐ NO ☐
Chairman’s name …………………….……………………….… Year Appointed …………………………
CEO’s name……….. …………………………………………….
Number of full-time staff ………………………………………. Number of part-time staff…………….…………………………..
Number of active volunteers who assist your Organisation with its programs/services …………………………………….
Community Collaborations & Partnerships
What other organisations in your local community serve a similar constituency (group of clients) or address similar needs
as your own? (20 words)
……………………………………………………………………………………….…………………………………………………..…
……………………………………………………………………………………….…………………………………………………..…
Have you undertaken any joint programs/projects with any of these organisations over the last year?
If YES, provide further information
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How does your organisation differ from those nominated above? (20 words)
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The Jack Brockhoff Foundation
Children and Youth
2014
THE JACK BROCKHOFF FOUNDATION
CHILDREN & YOUTH GRANT APPLICATION
PART C
YOUR PROJECT/PROGRAM – Title, Budget, Timetable, Description and Referees
Project/Program Title
Total Budget (expenditure) for this
Project/Program (include itemized budget as an
$
attachment to your application)
Amount requested from The Jack Brockhoff
Foundation (excluding GST)
$
Other Funding Sources (list the names of
$................................................................................................................
philanthropic foundations and other funding sources,
including Government from which you are seeking funding
from for this project; include the amount sought from each
and when an outcome is expected) As soon as you hear
from the source you MUST notify the Foundation.
Timetable for Project/Program Implementation
Amount
Source
outcome expected
$................................................................................................................
$................................................................................................................
...............................................
Commencement Date:
month/year
...............................................
Estimated Completion Date:
month/year
Description of the Project/Program for which
the grant is sought (maximum of 50 words)
..................................................................................................................
..................................................................................................................
..................................................................................................................
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Metropolitan Melbourne
Regional / Rural Victoria
Statewide
Geographic location of the people to be served
by this Project/Program
……………….................................................. (location)
……………….................................................. (location)
select ONE area only and nominate location
Has your organisation applied for a grant from
our Foundation before?
YES ☐ Please indicate the amount of grant received and when it was received
……………/……………(month/year received)
$........................................
NO
☐
Referees
Nominate two (2) referees not working for your Organisation
who would be prepared to speak or write in support of your
application (if requested to do so by our Foundation)
1.
.........................................................................................
name, position, organisation and contact number
2.
.........................................................................
...............
The Jack Brockhoff Foundation
Children and Youth
2014
THE JACK BROCKHOFF FOUNDATION
CHILDREN & YOUTH GRANT APPLICATION
PART D
DETAILS OF THE PROJECT/PROGRAM – Need addressed, Outcomes, Sustainability, Evaluation
Describe the need to be addressed and the people your Project/Program aims to benefit (20 words)
Include the approximate number of people who will benefit, including specific demographic or regional aspects, etc.
…………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………..
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Is this a new Project/Program?
YES/NO (delete as appropriate)
If NO, who has funded it in the past and what has been achieved to date and on what basis is there evidence that the program/project should
continue to be funded? (provide brief details only)
…………………………………………………………………………………………………………………..
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What are the Project/Programs anticipated outcomes? (30 words)
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Is there a likelihood of the Project/Program leading to beneficial outcomes for the broader community?
if YES, please briefly elaborate (20 words)
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Sustainable outcomes (20 words)
How will the benefits achieved from the Program/Project be sustained once grant funds have been expended?
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Evaluation and measurement of the Program/Project’s success (50 words)
Summarise how and by whom the effectiveness and success of your Program/Project will be measured
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Name and position of the
organisation’s representative
lodging this Grant Application
Name
………………………………………
Position
……………………………………….
Dated
……………………………………….
The Jack Brockhoff Foundation
Children and Youth
2014
THE JACK BROCKHOFF FOUNDATION
CHILDREN & YOUTH GRANT APPLICATION
PART E
CHECKLIST
Please review the following list to ensure all requested information has been supplied and that you have discussed your
project/program with a member of the Foundation’s staff prior to preparing or lodging a grant application. Omission of
requested information may result in your application being disregarded for consideration.
Read the Foundation’s Guidelines for Grant Applicants
☐
Verified that your Organisation is charitable, income tax exempt and has DGR endorsement
☐
Discussed your proposed project with The Jack Brockhoff Foundation staff to ascertain if the
Program/Project meets the Foundation’s current funding preferences
☐
Record here the date of your discussion or email communication ……………….
Completed all sections of the Grant Application (Parts A - E)
☐
Provided your Organisation’s latest audited Financial Statements/Annual Report
☐
Attached a copy of quotes (applicable if funding is sought for equipment)
NB. Please deduct the cost of GST from the requested amount as grants awarded will not include the GST
component
☐
Attached details of the itemized Project/Program budgeted expenditure
☐
Provided the names and contact details of two referees not associated with the project/program
☐
The Jack Brockhoff Foundation
Children and Youth
2014