All 2019 Community Road Safety Grants Project applications must be submitted via the Enquire online portal. Please do not use this form to lodge your application. This form is intended to be used for your business' internal use only, if required.

Department of Transport and Main Roads Community Road Safety Project Grant Application

Application by enter name of organisation for Round 8

Project ScopeProject ID00000000012

Title: (This will be the title that we will refer to for the entire life of the grant)

Example: Child Restraint Awareness and Access in Ayr

Which of the following would you be applying for? Select from this list: - Childhood Road Safety Education and Awareness (Kindergarten / Primary School) - Integrated Bike and Road Safety Education and Awareness (Kindergarten / Primary / Secondary School and Community) - Road Safety Education and Awareness - Motorcycle Safety Education and Awareness - Seatbelts Education and Awareness (in rural and remote communities) - Fatigue Education and Awareness - Pedestrian Education and Awareness - Safer Seniors Road Safety Education and Awareness

Summary of IdeaPlease provide a brief description of your proposed road safety related education and awareness project.

Who is your target audience? What are you doing? Where? Why? How? Benefit?

Project TimeframesWhat is your proposed start date?

Note: All approved projects must commence after 1 January of the next calendar year.

What is your proposed end date?

Your project must be completed within 12 months of your start date

Community benefitPlease provide dot points of the specific project deliverables.

For example, conduct 5x bike education sessions held on school grounds, road safety posters distributed throughout school environment, 5x public education sessions held at retirement estates across the sunshine coast.

What are your deliverables?

Community Need Describe the identified community road safety problem in your location.

Explain how the project will reduce and/or remove it.

Community Support*List community organisations you have consulted with and describe how these organisations are partnering with you on this project.

ExampleFamily Health Centre Office Accommodation $- Information Session Venue Hire $-

Poster (content & design) $10,000 00.

Project ContentPlease provide the following information on your proposed project.

Does your proposed projects course material already exists* (select from the drop down list)

Yes No

Please attach an outline of your proposed content under the Documents Upload screen.

How is road safety messaging reinforced to your target group during the life of your project: *

Please provide information on the number and type of resources available to manage the delivery of this project?

EvaluationDescribe what information you will collect to evaluate your project.

Identify a minimum of two (2) Key Performance Indicators (KPI’s) that you will measure your project against.Example:(1) 80% of sample group of families are correctly using the child restraint after 3 months.

Session / Workshop / Event DetailsPlease note: Each session should be its own line item.

Example:Participant organisation Address Audience Number of ParticipantsCommunity Health Centre 1 Smith Street, Ayr Families Approx. 100/year

Milestones (Project Plan and Timeline)Many tasks and activities are required to successfully deliver your project.

List each of the required activities and tasks that will be undertaken for the duration of this project. Note: You will need to schedule this project to commence the start of this project after 1 January in the next calendar year.

To assist in creating the below table, please consider the following questions:- How will the project be delivered? Include key milestones and deliverables and ensure these milestones are realistic.- What needs to be completed for your project to be successful?- When will any resources or promotional materials need to be created.- Who will your organisation need to engage?

Example:Note: Please ensure you give TMR 10 business days to review all resources and materials created by/for your project.

Task/Activity Start Date End DateRecruitment of facilitators/fitters 01/01/2020 30/01/2020

Budget & ExpensesDescribe your proposed project’s budget in detail. Include ALL elements you are seeking grant funding to pay for.

Notes:i) training / education session costs are to be identified on a per head basis (not session costs)ii) Internal organisations expenses (for example, printing, photography, videography, venue hire, administration and so on are not eligible. ii) refer to the current Rounds Community Road Safety Grants Project Guidelines

Note: All amounts are excluding GST.

Example:Item Quantity $ per item Sub-totalPoster (printing) 50 $1.00 $50.00Flyer (printing) 500 $0.80 $400.00

Total requestedFunding RequestPlease enter the GST exclusive amount that you are requesting. Note: This figure should line up with the budget table.

Other FundingPlease provide information about any funding or in-kind support being provided from other sources for this project. * * Include in-kind support from your organisation, project partners and local business and community groups. Include grants from other organisations, including government agencies

In-kind support, is a type of charitable giving in which, instead of giving money the applicant and/or community partners provides support towards your project. This can include voluntary labour or donated goods and services (for example, Marketing support, printing, room hire or donation of equipment) The calculation of in-kind support is based on your best estimate. The following figures may help guide you:- in-kind labour is normally calculated at $20 per hour- in-kind specialist contributions (eg. Services of a marketing executive) are normally calculated at $45 per hour.Note: It is your organisation’s responsibility to keep written records (eg. Letter of donations or receipts) of the in-kind support committed or received.

Note: Please ensure you provide this information as it demonstrates your organisation’s and the broader community's commitment to this initiative

Example:Organisation Item Quantity $ per item Sub-totalFamily Health Centre Office Accommodation $ Information Session Venue Hire $

Poster (content & design) $10,000 00Family Day Care Child restraints $5,000 max.

Barriers & RisksPlease identify potential or actual risks that may affect your project. This is an important aspect of all projects and will help you plan to manage those risks.

Example:Anticipated Risk/Barrier Prevention of anticipated Risk/BarrierDemand exceeds supply Family Day Care will supplement supply of child restraints up to

to $5,000 max. if need exceeds grant funding.

Team Details*must have access to the grant system EnquireNameMobile NumberEmail address

Primary Contact Details*The person who will be responsible for keeping the organisations details up to dateNameMobile NumberEmail address

Project Manager Details*The person who will be the main contact for any enquiries regarding the application and during the life of the grantNameMobile NumberEmail address

Authorised Officer DetailsThe person who has the legal authority to signa legal agreement and the one who will be receiving all correspondence including the Deed of AgreementNameMobile NumberEmail address

Project Partner Details Please provide details of any partnering organisations that are providing in-kind support and please include a letter of support from each organisationNameMobile NumberEmail address

NameMobile NumberEmail address

Conflict of Interest DetailsIs there a possible perceived, potential or real conflict of interest by yourself and/or your organisation?

No YesIf Yes, please complete and upload a Conflict of Interest form located at http://www.tmr.qld.gov.au/roadsafetygrants and attach at Documents screen.

Background Intellectual PropertyAll third-party intellectual property approvals are the responsibility of the applicant organisation. Please provide a description of all background intellectual property required for the project, including details of any third party rights to which the background intellectual property is subject.

“Background Intellectual Property” means intellectual property of a Party that is: (for example, copyright, patents, designs, trademarks) created by a party independently of the project. It may include, for example, a trademark of a project partner. You should also provide details of any agreement regarding your use of any background intellectual property.

InsurancesAll insurances (public liability, comprehensive motor vehicle insurance, workers compensation and so on) are the responsibility of the applicant organisation. Please provide relevant Certificates of Currency for the insurances required for your project

ExampleType Insurer Expiry date Total insured for Public Liability Big Company 31/12/2020 $20M

Acknowledgement and Declaration

• I certify that, to the best of my knowledge, the statements made in this application are true.• I have read and understood the current Community Road Safety Project Grants Guidelines (http://www.tmr.qld.gov.au/roadsafetygrants) and I understand that all conditions will need to be adhered to if my application is successful.• I acknowledge that the Department of Transport and Main Roads cannot guarantee funding for any application, and cannot guarantee funding to the full amount requested by any applicant.• I acknowledge that if the Department of Transport and Main Roads approves this application for a grant, I will be required to agree to the terms and conditions, submit progress reports and a final acquittal and evaluation report at prescribed times, as outlined in the Deed of Agreement.• I acknowledge that I have read and understood the privacy statement:o Privacy statement: The Department of Transport and Main Roads (the department) collects the information on this form for the purpose of assessing the application for a community road safety grant to address road safety issues in support of the strategic objectives set out within the Queensland Road Safety Strategy 2015-2021 and associated action plan.

Name:Position:Date:

Note: if you are not the Authorised Officer for your organisation, you must provide an acknowledgement and declaration signed by your Authorised Officer and upload via the Documents Upload page.

DocumentsUpload DocumentsPlease include documents such as:- Authorised Officer’s declaration- Course materials- Outline of proposed content- Signed letters of agreement from program partners identifying their role/contribution in the Program. IE School principal advising of approval to run your project at the school- Documents which support your application, such as:- Bank Statement for a valid bank account that matches the name of the legal entity identified on the application form- Evidence of Incorporation / Not-for-profit status- Insurance certificate- Third party property rights- Conflict of Interest declaration (if applicable)- ABN Lookup, including GST status

Documents attached