Hokonui Hauora Fund Application SECTION 1: Community group/organisation details Name of activity/event you're applying for: Does your community group/organisation have a Charitable Trust/services registration number or NZBN? Yes No If yes, please include here Funding criteria Community club or group Not-for-profit organisation or social enterprise Iwi organisations or Māori community group Multicultural council or ethnic community organisation Faith-based, religious and church group An informal group If you do not align with one of these categories, unfortunately you are not eligible to apply for funding. Note: An informal group (i.e. not a Trust, an Incorporated Society, Company or any other type of entity formed under New Zealand legislation) may be involved with managing a one-off event or a series of community activities. Area where your organisation is located: Organisation Email address: Organisation Phone number: (###) ### #### Organisation Website: http:// SECTION 2: Primary point of contact Details of the key person we should contact if we have any questions Name First Name Last Name Phone number: (###) ### #### Email address: Please write the name and phone number of two people from within your community group/organisation/committee that support this application: SECTION 3: Activity or event Is this an event/activity you have run in the past or a new event/activity: Short description of activity/event: Please list the benefits of your activity/event will have in terms of either the Five Ways to Wellbeing and/or Te Whare Tapa Wha models. (Remember to list as many benefits that relate to or fit these models): Date of activity/event: MM DD YYYY If applicable, list additional dates below: Location/venue: Who are you targeting to attend (demographics) and what is the expected number of attendees: SECTION 4: Fund Please state the total amount applied for (maximum $1,000 GST inclusive): $ Please detail how the money will be spent Note: Neither gifts nor alcohol can be funded. Applications must be not-for-profit. In particular, facilitator fees cannot be funded if you are the applicant (it would be considered self-funding. Please include details of any quotes, if appropriate (this would include proposed supplier and cost): Are you also applying for/receiving other funding support for this activity/event. If so, please state who the funder is and the amount you are applying for/recieved: SECTION 5: Applicant details Details of person submitting application on behalf of their community group/organisation: Applicant name: First Name Last Name Applicant position in the community group/organisation: I have the authority of my community group/organisation to lodge this application on their behalf: Yes No SECTION 6: Verification of Application If you are having difficulties adding files, format options etc. Please reach out to the following contact person and they will do there best to help you: tegan@hokonuirunanga.org.nz SECTION 7: Bank details Please enter your bank account number: Bank Account Name (as it appears on your statement): If you are having difficulties adding files, format options etc. Please reach out to the following contact person and they will do there best to help you: tegan@hokonuirunanga.org.nz SECTION 8: Declaration This section must be completed by a person within your community group/organisation that has the authority to apply for and enter into a funding agreement. Note: If you haven't already, please read the Hokonui Hauora Fund and the Hokonui Hauora Terms & Conditions thoroughly before completing this section. We acknowledge that the details given in this application, or supplied by us in support of our application, are true and correct to the best of our knowledge. We agree to provide information such as financial, statistical and or anonymised information to Hokonui Locality for the purpose of evaluating, auditing, reporting, and conducting enquiries on the initiative and/or funds. In accepting the fund, we agree to the terms and conditions. We acknowledge that Hokonui Locality will publish the names of the community group/organisations that receive funding, the amount, and its purpose. I have read and agreed to the above declaration and the terms and conditions of the Hokonui Locality fund Yes No Thank you for your submission!