Fillable SPORT NEW ZEALAND RURAL TRAVEL FUND APPLICATION FORM (Gore District Council New Zealand)

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SPORT NEW ZEALAND RURAL TRAVEL FUND APPLICATION FORM (Gore District Council New Zealand)

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1
SPORT NEW ZEALAND RURAL TRAVEL FUND APPLICATION FORM
2020/2021
Funding Round 1 – for Summer Sports
A. Details
Name of organisation: _____________________________________________
Contact person: _____________________________________________
Postal address: _____________________________________________
PO Box address: _____________________________________________
Telephone: ____________________Email:______________________________________
B. Contact names
Please provide
1. Name __________________________________ Phone _____________________
2. Name __________________________________ Phone ______________________
C. Organisation details
1. How many members belong to your club/organisation?
2. Are you a club or school?
3. Will the travel subsidy benefit participants aged between 5 and 19 years?
YES/NO (If so how many participants) __________________________
4. How many participants are aged between 5-12 years? ____________
5. How many participants are aged between 13-19 years? ___________
6. Does your application involve a partnership with a local school YES / NO
2
7. What is this funding going to be used for (briefly explain)?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
8. What percentage of your members live in the vicinity of the local authority you are
applying to for the rural travel fund? _______%
9. Has your club/organisation received funding from the Sport NZ Rural Travel Fund in
previous years? YES / NO (If so, when and how much).
________________________________________________________________________
________________________________________________________________________
D. Financial details
An answer to every question is required to validate your application.
1. Are you registered for GST? YES / NO
(If yes, please write your GST Number in the space provided below)
GST No:   
2. How much money are you applying for?*
$ ________________ (Your contribution from fundraising, fees etc)
$ ________________ (Other funders)
$ ________________ (Rural Sport Contribution)
$ ________________ (Total amount requested from Rural Sport NZ)
* Please use the space provided below to detail how this figure was calculated or append a
separate working sheet, including: distance travelled: ______ number of trips: ______ and
number of vehicles used: ______
3
3. Have you applied to any other organisation for funding and if so what was the result
(briefly explain)? Refer to Table 1 below.
Table 1
Organisation
(including other councils)
Amount
Requested ($)
Results date
(if known)
4. Do you have endorsement of your local affiliated club/school for this application for
funding? (This is only relevant if the group applying is the regional body).
YES / NO (briefly explain and attach evidence of this)
__________________________________________________________________________
__________________________________________________________________________
E. Declaration
We hereby declare that the information supplied here on behalf of our organisation is
correct?
We consent to the Gore District Council collecting the personal contact details and
information provided in this application, retaining and using these details and disclosing
them to Sport NZ for the purpose of review of the rural travel fund. This consent is given in
accordance with the Privacy Act 1993.
1. Name: _________________________________________________________
Position in organisation/title: _______________________________________
Signature: _________________________ Date: ______________________
2. Name: _________________________________________________________
Position in organisation/title: _______________________________________
Signature: _________________________ Date: ______________________
Please attach:
1. A balance sheet from your organisation (ie financial statement)
2. A deposit slip (in case your application is approved)
3. Evidence of endorsement from your local affiliated club/school (if required)
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4
Checklist:
Have you answered every question?
Have you detailed in the space provided how the amount of funding
applied for was calculated?
Have you attached a recent balance sheet for your organisation?
Have you attached a deposit slip (in case your application is approved?
Have you attached evidence of endorsement from your local affiliated
club/school if required?
Send your application form with the relevant documents by 5.00pm Monday 27 July
2020 to:
Karla Brotherston
Sport NZ Rural Travel Fund
Gore District Council
PO Box 8
Gore 9740
5
SPORT NZ RURAL TRAVEL FUND CRITERIA
The Sport NZ Rural Travel Fund is a partnership between Sport NZ and territorial authorities
to assist the development of junior sport in rural communities by providing a travel subsidy.
Each local authority has an assessment panel representative of its community, and these
panels make the funding decisions.
The Sport NZ Rural Travel Fund has funding available for this round to distribute to summer
sporting codes.
Who can apply to this fund?
Organisations and schools with participants between 5 and 19 years playing sport for a club
or school club team who meet the rural travel fund criteria.
Eligibility
Individuals are not eligible to make an application. All applications must come from sports
clubs teams, and school based teams. Funding should not be distributed to individual
players, coaches or officials for the purpose of travel.
The rural travel fund is to be managed by the Gore District Council and funding should not
be provided for the purpose of travel to regional or national events.
Funding Criteria
The following criteria shall be applied when considering application for funding. School club
teams and sport club teams are defined as:
“a school club team participating in regular local sport competition out of school time, that
excludes inter school and intra school competition played during school time”
and/or;
“a sports club team participating in organised, regular sport competition through club
membership outside of school time”
Conditions
Sport NZ requires organisations that receive funding to return an accountability form to the
Gore District Council, PO Box 8, Gore 9740 at the completion of the winter sporting season.
Please show proof of purchases made within that period and attach any receipts.
If applicant organisations, whom have received assistance, do not return their accountability
forms, it can jeopardise any future funding. Applicants must be able to account for the total
amount allocated.
To Apply
Applications must be made on an application form, available from the Fund Administrator
and must include the following:
A balance sheet from your organisation (ie. financial statement)
A deposit slip (in case your application is approved)
Evidence of endorsement from your local affiliated club/school (if required)
For further assistance please contact your Fund Administrator:
Suzanne Lucas at the Gore District Council Phone: (03) 209 0385.
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SPORT NEW ZEALAND RURAL TRAVEL FUND APPLICATION FORM (Gore District Council New Zealand)

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Completed 15 November 2020

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