CHASE Fund Project Proposal Outline

CHASE Fund Project Proposal Outline

Projects Category: Health
BASIC INFORMATION

Individual Applicant, Complete this section
Project Title:*
Type the name of your project
Date*

MonthDayYear
Date
First Name* Last Name* Street Address Address Line 2 City Area Code* Phone Number* Email*
TRN*
Tax Registration Number
Alternate Contacts
First Name* Last Name* Area Code* Phone Number* Email
First Name Last Name Area Code Phone Number
Email

BASIC INFORMATION

Organization Applicant, Complete this section
Name of Organization
Position
First Name Last Name Street Address Address Line 2 City Area Code Phone Number Area Code Fax Number Email

APPLICANT INFORMATION

Individual Applicant, Complete this section
Provide a Bio:*
Purpose for Application:*
Provide project undertaking experience/ achievements to date. (List major projects undertaken in the past and outline the approach to managing these project(s)):*

APPLICANT INFORMATION

Organization Applicant, Complete this section
Type of Organization and history (registration particulars):*
Number of members/staff:*
Purpose of Organization:*
Legal/Management Structure:*
Major source of Operating Budget:*
Main Achievements of the organization to date and/or describe major projects undertaken in the last five years (List major projects undertaken in the past and outline the approach to managing these projects):*

PROJECT SUMMARY

Organization Applicant, Complete this section
PROJECT CATEGORY (choose one)*

Building, Upgrading, Restoring or Equipping Health Facilities, Children’s Homes and Shelters for the HomelessProjects and Programmes for the Development of Healthy LifestylesSupport for the Mentally ChallengedPrevention of Drug AbuseTraining of Healthcare PractitionersDevelopment and Implementation of Programmes for Cancer Prevention, Detection, Treatment and Care.
Project Background/Description (State the why, what, and how of your project):*
Project Site Address:*
Purpose of Requested Funding (Briefly state what the funding is required for):*
Objectives of the project:*

Project Impact (Provide information on the expected benefits of your project):*
Beneficiaries (target group, numbers):*
Outputs and Incomes (expected results of the project)*
Duration (indicate expected start and end dates)*
Management (Explain how project will be managed; give the names and responsibilities of key management personnel):*

Total Project Cost:*
Amount Requested by CHASE:*
Other funding secured (indicate source and amount of funding received or committed):*
Risks and Challenges (State the main risks and challenges to your project meeting its aims and how they will be managed):*

DETAILED IMPLEMENTATION SCHEDULE AND BUDGET

Implementation Schedule (complete using EITHER date or month)
Activity:*
Schedule Type – Date
Schedule Type – Month (Month 1-12)

Project Budget:

List the prices of goods and services required for successful implementation of the project.

	Item Description	Unit Cost ($)	Qty	Total ($)	Requested from CHASE ($)	Equity (Your contributions to the project) ($)	Funding secured or committed by other sources ($)
Material-1
Material-2
Material-3
Material-4
Material-5
Total

BASIC INFORMATION