Application Form Review
A1
*Applicant name

(all correspondence will be sent to the applicant)
         
A2
Job title / Office

60 characters maximum (including spaces)
      
A3
Correspondence address
*Address1      
  Address2    
  Town    
  Region    
  *Postcode    
A4
*Telephone number

        
A5
*Email address

An acknowledgement and a copy of the application will be sent to this address, 60 characters maximum (including spaces)
      
A6
Co-applicant name

         
A7
Co-applicant job title

      
A8
Co-applicant e-mail address

      
A9
Co-applicant name

         
A10
Co-applicant job title

      
A11
Co-applicant e-mail address

      
A12
Co-applicant name

         
A13
Co-applicant job title

      
A14
Co-applicant e-mail address

      
A15
Co-applicant name

         
A16
Co-applicant job title

      
A17
Co-applicant e-mail address

      
A18
Co-applicant name

         
A19
Co-applicant job title

      
A20
Co-applicant e-mail address

      
A21
Who is your Service Manager ?

         
B1
*What is your project name ?

No more than 150 characters
      
B2
*Short project outline

900 characters maximum including spaces
      
B3
*Where will the project benefit ?

      
B4
*Proposed start date (month/year)

Must be within 4 months of the grant award letter
      
B5
*Project duration

As a guide 2 years maximum
      
B6
*Amount requested (as a guide between £5,000 and £50,000)

      
B7
*What costs are you requesting funding for ?

250 characters maximum (including spaces)
     ?
B8
What other funding options have you looked into for this project ?

4000 characters maximum (including spaces)
      
B9
If there are on-going costs (after the funded project ends), what are they and who will cover these costs

      
B10
*Select which theme best describes your project

      
B11
Select which of our strategic aims your project will meet
     
Improve the health of the local community

      
Improve the patient / carer experience

      
Help transform the healthcare system

      
Reduce healthcare inequalities

      
Investment in Preventive Medicine

      
B12
*Give a detailed project outline, ensuring that you demonstrate how it contributes to our strategic aims

2500 characters maximum (including spaces)
      
B13
*Give evidence that this project is needs-based

Describe the need that you have identified, how you have identified this and how this project has been designed to meet the need. 2500 characters maximum (including spaces)
      
B14
*Describe how the project will address equality, diversity and health inequalities, clearly stating which health inequality or inequalities you are addressing, and how this will be measured

2500 characters maximum (including spaces)
      
B15
*Describe how you will monitor and evaluate the success of the project at the end

No more than 2500 characters (including spaces)
      
B16
*Describe how the benefits of the project will be sustained, how you will disseminate any learning and how any ongoing costs will be met

2500 characters maximum (including spaces)
      
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