Order Brochures | Wolper Jewish Hospital

All sections of this form must be completed by providing responses in each field. Please assist us in ensuring your responses to all questions fit within the boxes provided.
Section 1
Organisation and contact information
Organization Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
ABN/ACN*
DGR status*
Email*
Legal structure of the organization*
Contact person name*
Contact person title*
Telephone number*
Mobile phone number*
Email*

Section 2
Initiative Information
a) Initiative Title*
b) Detailed description of the initiative*
Please describe the initiative for which you are seeking funding by providing the following information. Please include information on the current need or gap the initiative aims to address and how it will do this. (Maximum 100 words)
c) The goals and objectives of the initiative*
d) Who are the key people working on the initiative?*
e) Are there similar initiatives currently running? If so, how does this initiative differ?*
f) Is this a new initiative or an extension of an existing program or project?*
g) Is the organisation receiving funding, unrelated to this initiative, from other sources?*
Please provide details:
h) Is the initiative currently being funded by other sources? If so, please provide details.*
i) Is funding currently being sought from other sources or will funding be sought from other sources? If so, please provide details*
k) Is there any government initial funding or reimbursement related to this initiative?*
m) How will the initiative be funded if the Wolper Jewish Hospital Health Foundation can only provide partial funding?*
o) Will the expenditure be audited? If so, please outline how.*
p) Will the initiative be promoted? If so, please outline how*
q) Grant recipients are obligated to acknowledge the Wolper Jewish Hospital Health Foundation in their initiative promotion. Please outline how you will do this. See the Requirements Section of the Grant Application Guidelines document for details on acknowledging the Foundation.*

Section 3
Initiative evaluation
a) What are the expected results of the initiative? How will the initiative benefit the community?*
b) Who are the beneficiaries of the initiative and how many people will benefit?*
c) How will initiative effectiveness be measured? Please include a description of the key performance indicators used for assessing this initiative’s success.*

Section 4
Grant information
Total initiative budget Total funds requested*
Total funds requested*
Is recurring funding sought?*
- Yes
- No
If yes, over how many years and how much is required each year? Funding is available for a maximum of 3 years at a maximum of $20,000 per year.
Year 1*
Year 2*
Year 3*
Provide a detailed budget showing total costs of the initiative. Please also include costings of the components for which funding is being sought. Additionally, please provide financial reports for your organisation including the latest statement of financial performance and statement of financial position.*

Section 5
Referees
Please nominate two referees not involved with the initiative that can vouch for the organisation’s ability to successfully manage the proposed initiative. Alternatively, please supply a written reference, testimony, or supporting documentation:
Referee 1
Referee Name 1*
Position title*
Company*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Telephone number*
Mobile number*
Referee 2
Referee Name 2*
Position title*
Company*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Telephone number*
Mobile number*

Section 5
Declaration
By completing the signature box below you are confirming the following:
Applicant Name*
Position held*
Signature*

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Date*
MM slash DD slash YYYY

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