Individual Small Grants Application Form ; APPLICANTS DETAILS First Name* Surname* Date of Birth* Your Email Address* Suburb* Postcode Contact Number* SUPPORTING ORGANISATION Contact Person* Email Address Suburb Postcode Contact Number ACTIVITY DETAILS Activity Start Date: Description of Activity How will the item / activity help you? What events, recreation ideas or what would you to have in the region? How do you get around in the region? Would you be interested in helping to plan for a Youth Friendly Barossa?YesNo Any other comments? BUDGET DETAILS: - Amount sought through this application (not to exceed $500.00) Have you received Individual Small Grant funding previously?YesNo If yes, date received, amount and purpose Details of how this grant will be spent: Input one item per line and delete example text. Example: Bags: $40.00 T-shirts: $40.00 Pens: $40.00 Pads: $40.00 Total Amount Sought: $160.00 Other IncomeIf grant exceeds $500, please list here what other income will finance the total cost of this activity? Who should payment be issued to? Please note - payment will not be made direct to the applicant. (This section MUST be completed) Organisation: (ie. Name of driving school) Account Name: BSB: Account Number: INFORMATION CHECKLIST I have reviewed individual Small Grant Scheme Guidelines (www.youthbarossa.com.au/about-youth-grants) and my activity is eligible I have obtained two written quotes and uploaded them with this application) Requested grant funding amount to the value of or less than $500.00 Any supporting information is uploaded with this application I have attached a signed letter of support from my supporting organisation Supporting Quotes & Documents Quote#1 Quote#2 Letter of Support Supporting Documents APPLICANTS DECLARATION I have read and understand the conditions of the grant, and hereby agree to be bound by them. I declare that this application form has been completed accurately and all information given is true and correct and that no pertinent information which may affect this application has been omitted or withheld. Date:
