NT Organisation Grant Application

"*" indicates required fields

Should you need any assistance with this form, or have any questions, please get in touch with us by calling 08 8981 2544 or email [email protected].

1. Organisation's Details

Organisation Name*

Tell us about your organisation.*

Number of children catered for (under 18yrs)*

Age range*

Number of children who identify as Aboriginal or Torres Islander origin*

Number of children with a disability*

Please list the types of special needs or disabilities catered for

How many children from a Non English Speaking Background, or have a parent who was born overseas?

Contact Details

Name*

Title First Name Last Name

Position*

Contact number*

Organisation Physical Address*

Street Address City State Postcode

Postal Address

If different from above

2. Details of Grant Request

Details of item/s requested and how the item/s will be used*

Explain three (3) outcomes you expect to be achieved if this grant is approved

Outcome 1*

Outcome 2*

Outcome 3*

How many children will benefit from this grant in a 12-month period?*

Cost*

Must include GST & freight as appropriate

Amount Requested from Variety NT*

Must include GST & freight as appropriate

Please attach quote*

Max. file size: 512 MB.

Please attach a second quote (if available)

Max. file size: 512 MB.

Number of year’s equipment expected to last:*

Preferred Supplier Name:*

Please provide a minimum of 2 quotes, unless there is only one manufacturer.

Preferred Supplier Address*

Preferred Supplier Phone Number*

Preferred Supplier Email Address*

Financial Details

Please give an overview of your organisation's past and current fundraising activities*

Are you able to make any financial contribution to this application?*

How much are you able to contribute?*

Have you approached any other sources for financial assistance?*

Does your organisation receive outside financial assistance?*

(From corporate sponsors, charities, government grants etc.)

Please detail*

Can this item be funded by the Department of Education or other Government funding?*

As this item can be funded, please explain this request to Variety NT

If you know why this can't be funded, please give details

Have you previously received assistance from Variety NT?*

Please detail equipment and year of grant*

Application Reference (if known)

3. Consent Details

Please note that your answers have no bearing on the outcome of your application

I / We give consent for Variety NT to generate publicity through print and electronic media, and / or request to participate in a presentation, should this application be successful.*

I / We would like to join Variety NT's mailing list, to hear all of Variety's latest news.*

If your application is approved, how will you acknowledge Variety NT's contribution?*

6. Referral

How did you hear about Variety NT?*

Other, please give details*

6. Privacy Collection Statement

Your privacy is respected by Variety NT. The personal information you provide on this form (including sensitive information about the health of the children in your care) will be used to assess your eligibility. If you do not provide the requested information, we may be unable to confirm your eligibility. Your personal information may be provided to organisations that assist us including overseas organisations in the United States of America and elsewhere, or as required or authorised by the Privacy Act 1988 (as amended). We will not use any of your sensitive information for marketing purposes, without your prior consent. If you have any privacy concerns or would like to verify or correct information held about you please contact Variety NTon 08 8981 2544. Further information including how you can complain about a breach of the Australian Privacy Principles can be found in our Privacy Policy available at http://www.variety.org.au/privacy/.

By ticking below, you confirm that you have read and agree to Variety’s guidelines. Submission of this application to Variety NT does not expressly mean or imply that Variety has accepted your application. Variety NT is under no obligation, legal or otherwise, to process your application to a successful conclusion. Each application will be determined on its merits, and within Variety NT's funding guidelines. Variety NT is not liable for any loss or damage whatsoever upon your application being declined. By submitting this application to Variety NT, you acknowledge that any and all implied terms and conditions or warranties implied by law are excluded. You acknowledge on making this application that Variety NT has not made any representation, or given any promise or undertaking as to the fitness of any equipment or product(s) sought to be supplied to you in pursuant to this application. It is solely for you to determine whether the equipment or product being sought is fit for its purposes. Variety NT may arrange for the supply and delivery of equipment or a product, but it is neither the vendor nor the supplier of any equipment or product. Accordingly, Variety will not be responsible for any direct or consequential loss or damage arising or related in any way to this application or its subject matter.

Declaration*

I consent to Variety NT collecting the information provided on this form. I have read and agree to Variety NT's guidelines. I understand that if I do not provide the information requested, I may be ineligible to receive assistance from Variety NT.

Date*

Thank you for your time to complete this application. Please check your email inbox for updates as the application progresses (check junk/spam if not in your immediate inbox).

Application vetting is carried out by our Kids Support Committee. Please allow 1-2 weeks for updates following confirmation of receiving your application. Feel free to check on the form at any stage by calling 08 89812544 or email [email protected]

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