Active Communities Fund
Application Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Age
*
Are you currently a member of a Sports Club/Activity? If not, what Sports Club/Activity are you wanting to be involved with?
*
Have you approached other organisations for funding?
*
Yes
No
Have you received support from the Active Communities Fund in the past?
*
Yes
No
If yes, please state the year and what was the purpose of the support (e.g. paid fees to play basketball, etc.).
Do you (applicant) or your caregiver hold a Community Services Card?
*
Yes
No
Please attach a copy of your (or your caregiver's) Community Services Card (if applicable).
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Purpose and kind of assistance needed
Add a description and a cost to each item
Item/Description/Total Cost
*
Rows
Description (What & How many)
Total Amount in $
Club/Activity fees/Subscriptions
Uniform
Footwear
Equipment
Travel Costs
Individual/Group Coaching
Total $ applied for
*
Please attach invoices/quotes related to the expenses you are applying for
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Provide an outline of your proposed costs
*
Applicant's Signature
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Parent/Guardian Information
If the applicant is under 18 years old.
Name of parent or guardian
First Name
Last Name
Address (if different to applicant's address)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (if different to applicant's number)
-
Area Code
Phone Number
Email
example@example.com
Parent/Guardian's signature
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Sponsor's Information
Sponsor's Name
*
First Name
Last Name
Sponsor's Email Address
*
example@example.com
Sponsor's Phone Number
*
-
Area Code
Phone Number
Sponsor's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sponsor's Position/Role/School/Agency
*
Please attach a letter from your sponsor supporting your application. The letter should contain: the sponsor's information, a detailed account about what type of assistance you need from this fund, any other evidence that supports your application, and his or her signature above the following text: "By signing this application, I agree that to the best of my knowledge, the applicant fits the criteria and is a worthy recipient of the fund. I will also remain involved with the individual/family as a result".
*
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Disclaimer
If my application is approved, I:
*
Rows
Confirmation
Will use the funds for the purposes originally stated in this application .
Agree to provide Sport Manawatu with all the evidence they may require regarding the use of the funds.
Agree to submit a report about the impacts and incidental outcomes from receiving the Fund.
Acknowledge that failure to submit the report may disqualify me from re-applying to the fund.
Allow Sport Manawatu to use the information I provide to help improve and perpetuate programme.
Will abide by the conditions of the Active Communities Fund.
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