Hutt Valley Pacific Community Activation Fund

Pasifika Hutt Valley Community Activation Fund

Apply for Hutt Valley Pacific Community Activation Fund

The Hutt Valley Pacific Community Activation Fund has been established by Pacific Health Services Hutt Valley and Te Awakairangi Health Network to enable Pacific communities and groups to prepare, respond, absorb, adapt and adjust to the impacts of the evolving nature of COVID-19.

Applicants can apply by submitting a costed proposal up to $5,000.

Any questions can be directed to info@phshutt.co.nz or (04) 577 0394

Please review all of the application questions below and required documents that need to be included. For longer answers you may want to copy and paste text from another document into this form.
1. Organisation Information
Organization / Group Name:*
Please use registered name if relevant
Church / Religious GroupEthnic Specific GroupSporting GroupYouth Led GroupSocial Services ProviderArts, Languages and Culture GroupOther Community GroupNGOLGBTQIDisability RelatedOther
Where in the Hutt Valley will your initiative be delivered? (Please list below)*

0/500
2. About your initiative
What is the name of your project/initiative?*

0/500
Please tell us a bit about your organisation or group:*
Provide a detailed description of your initiative and list what you want to deliver. (What are you trying to achieve through your project? What are the deliverables? Why is it important?)*
What are the intended outcomes of your initiative?*
What are the benefits of your initiative?*
What activities will be undertaken, and how do these relate to the objectives of the fund?*
All Pacific communitiesEthnic specific communitiesLGBTQI communitiesChurch/religious communitiesYouth and young persons communitiesElderly communityDisabled communitiesOther
0-20 people21-50 people51-100 people100+ people
Start date of your initiative

MonthDayYear
End date of your initiative

MonthDayYear
3. Funding
How much funding are you applying for? (Must be under $5,000 excl. GST):*
YesNo
YesNo
If you answered YES to the previous question, please specify below (I am currently funded by ... for the following projects...):
YesNo
4. Primary Applicant Details
Title / Cultural Title / Matai (if relevant):
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
Contact Phone Number:
Best contact numberFormat: (000) 000-0000.
5. Secondary Applicant Details
Title / Cultural Title / Matai (if relevant):
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
Contact Phone Number:
Best contact numberFormat: (000) 000-0000.
6. Supporting Documents

Please prepare your budget expenditure proposal for this initiative as a separate document.
Document Upload

Click to upload file
Cancelof
Please make sure your documents are saved in .doc, .docx, xls, xlsx or PDF file format and include your business or organisation/group name in the filename when saving and uploading.
7. Declaration
In digitally signing this Declaration, I:

· Confirm the information contained is true and accurate.

·        Confirm I have read and understood my rights regarding the Privacy Act 2020.

·        Confirm this initiative complies with the objectives of my organisation.

·        Understand that there is no guarantee that my organisation/group will be successful in securing any funding from PHSHV or Te AHN.

·        Agree that the PHSHV and Te AHN may collect information about my organisation from any third party in respect of this application.

·        Agree that, if the application is successful, the name of my organisation/group, purpose of investment and the amount will be available as part of the accountability for public funds.

·        Agree that the information provided in this application can be used for statistical purposes and/or policy development.

·        Agree that, if successful, my organisation/group may be required, along with the targeted beneficiaries of the proposed project, to participate in an evaluation of the initiative.

·        Accept full accountability and responsibility for all requirements associated with the completion of the initiative.

Understand that the personal information I am being asked to provide is necessary to help determine how the PHSHV and Te AHN might be able to assist me with my funding aspirations, including eligibility for practical and financial assistance. I understand I have the right to request access to MY personal information held by PHSHV and Te AHN and, if appropriate, request that the information be corrected.
YesNo
Name
Role in your organisation or group (if applicable):
Following your submission, you should receive an email confirming receipt of your application. If you haven’t received a confirmation email within 24 hours, please email info@phshutt.co.nz.

You may be asked to provide your bank verification in the name of the organisation or group applying, as well as a GST invoice from any third-party suppliers. If this information is required, we will email you.

Questions?
Send questions about your application to: info@phshutt.co.nz.
Should be Empty:

Pasifika Hutt Valley Community Activation Fund

1. Organisation Information

2. About your initiative

3. Funding

4. Primary Applicant Details

5. Secondary Applicant Details

6. Supporting Documents

7. Declaration