APPLICATION FORMStrand 2

Healthy Ireland Fund – National Actions

CLOSING DATE FOR APPLICATIONS IS:

Wednesday 23rd August 2017 @ 3pm

Please read the application guidelines before completing this form

Contact Pobal by email at healthyirelandfund@pobal.ie or by telephone

at 01 5117161

Where you see “choose an item” in this form a list of options are provided, please select your option by clicking on “choose an item” and then clicking on the side bar arrow to view and select your options.

Title of your project (optional)

Enter the total amount of grant applied for €

Organisation details 1 Legal name of your organisation

2 Address Address 1

Address 2

Address 3

Town

County

Eircode3 Telephone number for your

organisationLandline

Mobile

4 Tax Registration Number (TRN)

5 Organisation website address

Primary contact person for the project in your organisation5 Name of primary contact person

6 Role within the organisation

7 Landline Mobile

8 Email

Chairperson/CEO contact details9 Name of Chairperson/CEO

10 Telephone contact details Mobile

Landline

11 E-mail address for Chairperson/CEO

Governance and financial management of the project

12 What are the proposed governance and reporting structures for the project? Provide specific details in relation to the overall management and administration of the project. You may attach a chart to assist in explaining the reporting structure.

13 What are the financial management arrangements for the project? Include a summary on the internal controls, management of the budget, accounting and financial reporting, disbursement of funds for the project, financial arrangements with any partner organisations.

14. National Actions for a Healthy Ireland

List the key national actions in the table below that will raise awareness of the positive benefits of physical activity and/or promote wider participation in physical activity.When you click on “choose item” in the tables below, a list of dropdown options will appear. You can select one item only. The table has no character or word limits however please be as concise as possible in your responses.

Information Required

Explanation

Title Provide a name for each key action e.g. “Get Ireland Walking”.

Description Provide an overview of the action, maximum of 3-4 sentences. Actions may be an entire activity or may be a discrete component that adds value to any existing programme or project.

Milestones Identify the significant phases of work in relation to this action with indicative dates, i.e. what must be achieved by specific dates in order to complete the action.

Target group Tell us who will directly benefit from each action, in particular highlight any vulnerable groups of people. Vulnerable groups for the purpose of this fund are: Children, young people and adults living in areas of social-economic disadvantage; Children, young people and adults with disabilities and or chronic illnesses (including mental health issues); Unemployed young people and adults; Children, young people and adults from new communities (including asylum seekers and refugees); Children, young people and adults from the travelling community; Children, young people and adults from other minority groups e.g. LGBTI; older people.

Action co-ordinator Tell us who is responsible for ensuring that the action happens and all tasks associated with the action are undertaken.

Partners Tell us about any partners (formal and informal) involved in the planning and/or delivery of this action e.g. public, private, community/voluntary organisations. All actions must have a cross-sectoral approach to planning or delivery.

Outputs Tell us what anticipated results will be achieved immediately after implementing this action. For example, number of people who will participate in an event or activity; number of initiatives that will be implemented.

Alignment with Healthy Ireland Framework

Tell us how the action will complement or contribute to objectives and actions outlined in the Healthy Ireland–A Framework for Improved Health and Wellbeing 2013-2015. For information go to the Healthy Ireland website. In particular outline how the action is aligned to the National Physical Activity Plan, the National Sexual Health Strategy, Tobacco Free Ireland, the Obesity Policy and Action Plan

Procurement Tell us about your intentions in terms of procuring goods and services in relation to this action e.g. tendering, sub-contracting.

Total cost of this action

Complete the budget template sent to you with this application form. Insert the total cost for each action in the table below. Please ensure that the figures in each table correspond to the figures in the budget template.

Action 1 .Start Date for the action End date for the action

Description of the action Enter description here

Milestones Date to be completed by

1 Milestone 1 Date 12 Milestone 2 Date 23 Milestone 3 Date 34 Milestone 4 Date 4

Target group(s) for this action

Action co-ordinator

What partners are involved in the planning and delivery of this action?

List the output(s) for this action

Demonstrate how this action aligns with the Healthy Ireland Framework and the National Physical Activity Plan

Tell us how you intend to procure the services or goods required to implement this action

Does this action require the employment of staff?

Choose an item. Choose an item.If yes enter job title and attach job description template to your application

Total cost for this action €Total Cost

Action 2 .Start Date for the action End date for the action

Description of the action Enter description here

Milestones Date to be completed by

1 Milestone 1 Date 12 Milestone 2 Date 23 Milestone 3 Date 34 Milestone 4 Date 4

Target group(s) for this action

Action co-ordinator

What partners are involved in the planning and delivery of this action?

List the output(s) for this action

Demonstrate how this action aligns with the Healthy Ireland Framework and the National Physical Activity Plan

Tell us how you intend to procure the services or goods required to implement this action

Does this action require the employment of staff?

Choose an item. Choose an item.If yes enter job title and attach job description template to your application

Total cost for this action €Total Cost

Action 3 Start Date for the action End date for the action

Description of the action Enter description here

Milestones Date to be completed by

1 Milestone 1 Date 12 Milestone 2 Date 23 Milestone 3 Date 34 Milestone 4 Date 4

Target group(s) for this action

Action co-ordinator

What partners are involved in the planning and delivery of this action?

List the output(s) for this action

Demonstrate how this action aligns with the Healthy Ireland Framework and the National Physical Activity Plan

Tell us how you intend to procure the services or goods required to implement this action

Does this action require the employment of staff?

Choose an item. Choose an item.If yes enter job title and attach job description template to your application

Total cost for this action €Total Cost

Action 4 Start Date for the action End date for the action

Description of the action Enter description here

Milestones Date to be completed by

1 Milestone 1 Date 12 Milestone 2 Date 23 Milestone 3 Date 34 Milestone 4 Date 4

Target group(s) for this action

Action co-ordinator

What partners are involved in the planning and delivery of this action?

List the output(s) for this action

Demonstrate how this action aligns with the Healthy Ireland Framework and the National Physical Activity Plan

Tell us how you intend to procure the services or goods required to implement this action

Does this action require the employment of staff?

Choose an item. Choose an item.If yes enter job title and attach job description template to your application

Total cost for this action €Total Cost

Action 5 Start Date for the action End date for the action

Description of the action Enter description here

Milestones Date to be completed by

1 Milestone 1 Date 12 Milestone 2 Date 23 Milestone 3 Date 34 Milestone 4 Date 4

Target group(s) for this action

Action co-ordinator

What partners are involved in the planning and delivery of this action?

List the output(s) for this action

Demonstrate how this action aligns with the Healthy Ireland Framework and the National Physical Activity Plan

Tell us how you intend to procure the services or goods required to implement this action

Does this action require the employment of staff?

Choose an item. Choose an item.If yes enter job title and attach job description template to your application

Total cost for this action €Total Cost

Action 6 Start Date for the action End date for the action

Description of the action Enter description here

Milestones Date to be completed by

1 Milestone 1 Date 12 Milestone 2 Date 23 Milestone 3 Date 34 Milestone 4 Date 4

Target group(s) for this action

Action co-ordinator

What partners are involved in the planning and delivery of this action?

List the output(s) for this action

Demonstrate how this action aligns with the Healthy Ireland Framework and the National Physical Activity Plan

Tell us how you intend to procure the services or goods required to implement this action

Does this action require the employment of staff?

Choose an item. Choose an item.If yes enter job title and attach job description template to your application

Total cost for this action €Total Cost

15 How will you monitor and record progress in relation to all actions, to ensure that your project is completed by the end of March 2018?

16. Project Budget

Please complete the budget template sent out with your application form.

Please note the following when preparing your budget.

You are required to provide detailed explanations for each of the costs applied for under each action.

Core costs of your organisation are not eligible. For example, rent, light and heat, ICT, insurance, service charges, core staff costs, central administration costs.

Small pieces of equipment for seconded staff such as laptops are not eligible. All costs included in the budget must be directly related to the implementation of the

project proposed, and verifiable i.e. at a later date the expenditure incurred must be supported by evidence such as an invoice. You are not required to submit quotations or tender information with your budget, as part of the application process.

You are required to follow public procurement guidelines in implementing this project proposal.

Major capital works and routine repairs of buildings and equipment are not eligible.

Refer to the application guidelines for a more detailed list of eligible and ineligible costs.

Please include a clear explanation and justification for each cost applied for on the budget template

Additional information17. Please provide any other information which you think is relevant to this

application

18. Documents required to be submitted with your application form

If attached please click to

insert “x”

Hyperlink to website(optional)

1 Organisational Chart for the governance and management of the project (Optional)

☐

2 Job Description Template (Mandatory if staff costs are included in the budget template)

☐

3 Budget Template (Mandatory) ☐

19. Disclaimers

A. Disclosure under the Freedom of Information Act

Under the Freedom of Information Act 2014, the information in this application form and its attachments may be released on request to third parties.

If you believe that any of the information in your application form is sensitive and should not be disclosed to a third party, you must identify the sensitive information and provide the reason(s) for its sensitivity.

You may be consulted about the sensitive information before any decision is made to release the information to a third party.

Please outline the sensitive information and the reason(s) for the sensitivity in the text box below.

B. Data Protection

In submitting this application to Pobal, your organisation (and project partners) agree that:

No sensitive personal data should be included on this form. Sensitive personal data is defined as data relating to a person's racial origin; political opinions or religious or other beliefs; physical or mental health; sexual life; criminal convictions or the alleged commission of an offence; trade union membership. In this case, sensitive personal data may also refer to the inclusion of names, addresses and/or ages of service users or project beneficiaries in your application form.

Your organisation authorises Pobal to use, process and store the information in this form for the purposes of assessing your proposal for funding, the administration of any grants awarded by the Healthy Ireland Fund and the production of internal and external reports relating to the Healthy Ireland Fund.

In its management of the Healthy Ireland Fund, Pobal may transfer any data it has received from, and any data it holds relating to your organisation to other persons and bodies, such as the Department of Health.

If a third party is acting on your organisation’s behalf, Pobal is authorised to use, process and store data received from this third party and to forward to the third party, any data relating to your application, Pobal’s appraisal of your application and your organisation’s delivery of projects supported by the Healthy Ireland Fund. Pobal may also procure data from third parties to assess your application.

It is your organisation’s responsibility to ensure that any sensitive personal data submitted is obtained with the individual’s consent and knowledge that the data will be used for the purposes of this application. By submitting this application form, your organisation confirms that consent has been obtained from any individual whose data is disclosed within the application form.

Tick box to confirm that you have read and agree with the above data requirements. ☐

20. SUBMISSION OF APPLICATION

Please read carefully before submitting your application.

The CEO and/or board of the organisation, by submitting this application:

Declare that they are submitting the application on behalf of their organisation; Declare that the information provided in the application form and attached documents are

true and accurate; Accept that Pobal may contact funding organisations or government departments to

discuss this application and previous funding awarded, as part of the selection process; Have the co-funding in place as described in the application form (if applicable); Accept that the Department of Health or Pobal shall not be liable to the applicant or any

other party in respect of any loss, damage or costs of any nature arising directly or indirectly from:

a) The application or the subject matter of the application;b) The rejection for any reason of any application.

Accept that the Department of Health or Pobal, their servants or agents, shall not at any time or in any circumstances, be held responsible or liable in relation to any matter whatsoever arising in connection with the development, planning, construction, operation, management and or administration of an individual project.

Confirm that the costs applied for are not retrospective costs i.e. expenditure that has already occurred.

Confirm that should the application be successful, the nominated contracting body will comply with the DPER Circular 13/201.4 – Management of and Accountability for Grants from Exchequer Funds. http://circulars.gov.ie/pdf/circular/per/2014/13.pdf

Name (CEO or designate)

Position