DIABETES WA STRONG CULTURE: A ROAD TO GOOD HEALTH SMALL GRANTS SCHEME APPLICATION FORM

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1 DIABETES WA STRONG CULTURE: A ROAD TO GOOD HEALTH SMALL GRANTS SCHEME APPLICATION FORM APPLICANT DETAILS School/Organisation Name Grant amount requested Australian Business Number (ABN) Are you an incorporated, not-for-profit association? Are you registered for GST? Contact Name Principal s Name Postal Address Street Address Details of financial institution (these will be used to deposit funds if your application is successful) Account Name Account Number BSB Number TARGET GROUP Please indicate the estimated reach of your project to the following demographics: Primary school aged High school aged Caregivers/Family Community members Aboriginal or Torres Strait Islander Non Aboriginal Torres Strait Islander EXISTING HEALTH PROMOTION PROGRAMS AND STRATEGIES Please indicate if your school/organisation has any existing health promotion strategies or programs: Breakfast program Crunch&Sip Healthy food policy Alcohol/drug awareness Sexual health Bullying prevention Smoking awareness Mental health Other (please list):

2 PROJECT PLAN Project Title: Is this a new initiative for the school? YES/NO PLEASE PROVIDE A DESCRIPTION OF YOUR PROJECT/INITIATIVE: PROJECT TIMELINE Please use the timeline below to show milestones/tasks, or to show a session schedule. Give as much detail as possible. You may wish to provide this in a separate document. Examples: 01/10/14 Session One Use Module One of Strong Culture manual. Diabetes talk from local community health worker. Elder to talk about their experience living with diabetes. 01/10/14 First project working party meeting for Healthy Cook Up event. Tasks to be delegated include Date/ Week no. Details of milestone/task/activity

3 WHAT ARE THE EXPECTED OUTCOMES OF THE PROJECT? FOCUS AREAS Please provide details of how your project will address the following focus areas: Diabetes Education diabetes prevention messages? Nutrition/Healthy Eating nutrition and healthy eating messages? Promoting Water How will your project promote and/or provide water as the main drink?

4 Physical Activity physical activity messages, and incorporate physical activity in practice? Culture How will you ensure your project is culturally appropriate and draws upon local traditional knowledge? PARTNERS AND STAKEHOLDERS Please provide a list of internal (school/organisation staff) and external stakeholders and their role in your project: Partner/Stakeholder Eg. Aboriginal Medical Service dietitian Classroom teacher Elder Role Delivery of diabetes and nutrition session Facilitate physical activity session Yarn with students about experience living with diabetes BUDGET Please outline each expense related to the project. Attach quotes where available. Expense Amount TOTAL

5 ATTACH CERTIFICATE OF CURRENCY FOR: Workers compensation insurance Public liability insurance Professional indemnity insurance CONDITIONS OF GRANT If your application is successful, the budget and project plans detailed in your form will form part of your contract with Diabetes WA. AGREEMENT We agree to: - The grant conditions outlined in the Applicant Information - To acknowledge the support of Diabetes WA and the Australian Government - Department of Health in writing through the placement of the Diabetes WA logo where appropriate - That any changes (including timelines, target group, or budget) must be approved by Diabetes WA in writing DECLARATION To be completed by an authorised officer. I am authorised to agree to the above conditions on behalf of the applicant organisation and that all statements made in this application are true an accurate to the best of my knowledge. Name: Signature: Date: PRINCIPAL SIGN-OFF (If principal is not application contact) I (name) acknowledge this grant application. Signature: Date: Position (please circle): Principal/Vice Principal