About Your Organisation Name of organisation: Contact Address Address Address 2 Town Postcode Main Contact Name Position Email Phone Alternative Contact Name Position Email Phone What type of organisation are you? Registered Charity Social Enterprise Community Interest Company Not-for-Profit Community Business Unregistered Community Group Club Society What is your registered number if you have one? What are your organisation’s main or current activities? 500 characters maximum Please tell us, thinking about our funding criteria, how your project will help us achieve these objectives. 1000 characters maximum About Your Project Please describe your project Max 1000 characters. You may use less. Please give us three goals of your project. Take into account the people you are working with. These aims should reflect the people you work with and show an understanding of your community. Estimated Project Start Date Estimated Project End Date The fund has wider outcomes, please order these in focus for your project. This is for our project monitoring but also to make sure you get the right resources for help you deliver. Start with number 1 as your main priority and then arrange the rest in order of focus / priority. Weight Increase Early Presentation For Prostate Cancer Weight for Increase Early Presentation For Prostate Cancer -7-6-5-4-3-2-101234567 Increase Bowel Screening Uptake Weight for Increase Bowel Screening Uptake -7-6-5-4-3-2-101234567 Increase Cervical Cancer Screening for 50+ Weight for Increase Cervical Cancer Screening for 50+ -7-6-5-4-3-2-101234567 Increase Screening For Breast Cancer Weight for Increase Screening For Breast Cancer -7-6-5-4-3-2-101234567 Wellbeing Messages That Support Cancer Prevention Weight for Wellbeing Messages That Support Cancer Prevention -7-6-5-4-3-2-101234567 Cancer Myth Busting Weight for Cancer Myth Busting -7-6-5-4-3-2-101234567 Honest / Innovative Engagement & Conversations Weight for Honest / Innovative Engagement & Conversations -7-6-5-4-3-2-101234567 Tell us about the people you work with and how far your messages may spread. Max 500 characters We want to understand your people and make sure multiple groups are covered by this fund. We also want to make sure the messages are going to as many people as possible. Financial Information Please give details of the costs for the project Please break down as appropriate e.g. hourly rates, hours per day/week etc. Make these figures as accurately as possible, do not estimate or round up. Total project cost applied for Please make this as accurate as possible. Are you seeking further funds from any other organisation for this programme? Yes No Other… If yes, please give details of the amount and when the outcome will be known: Have you applied for the same service to another area? Yes No Other… If Yes please explain if the project can delivered independently or if cost savings can be made Declaration & Documents Before signing the declaration, please ensure you have completed all the sections in this application form, and that you upload the documents requested on the checklist below where applicable. Declaration I am an authorised representative of the organisation. To my best knowledge, the information provided in this application form is correct. Representative Information Electronic Signature / Type Name Position In Organisation Date