NZCT Manawatū Active Communities Fund
Application Form
Name (individual applicant)
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 (individual applicant)
Gender
*
What is your ethnicity?
*
NZ European / Māori / Pasifika, etc
Are you currently a member of a Sports Club/Activity? If not, what Sports Club/Activity are you wanting to be involved with or looking for support with?
*
Have you approached other organisations for funding?
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Yes
No
Have you received support from the NZCT Manawatū Active Communities Fund in the past?
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Yes
No
If yes, please state the year and what was the purpose of the support (e.g. paid fees to play basketball, etc.).
What are the barriers that prevent you from being active?
*
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Purpose and kind of assistance needed
Add a description and a cost to each item. Individual items over the value of $250 each will be at the descretion of the panel.
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 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. (for individual applicants only)
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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Champion's Information
E.g. club administrator, teacher, etc.- someone who can support your application. (for individual applications only)
Champion's Name
*
First Name
Last Name
Champion's Email Address
*
example@example.com
Champion's Phone Number
*
-
Area Code
Phone Number
Champion's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Champion's Position/Role/School/Agency
*
Please attach a letter from your Champion supporting your application. The letter should contain: the Champion'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 Manawatū with all the evidence they may require regarding the use of the funds.
Agree to submit a survey response about the way the fund helped me within a timeframe communicated to me at the time of acceptance.
Acknowledge that failure to complete the survey may disqualify me from re-applying to the fund.
Allow Sport Manawatū 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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