dca grants application form · dca grants application form 2 . ... theatre visual arts and crafts...

To complete this form correctly, you will need to refer to the relevant program handbook AND the DCA Grants - A Guide to Completing Your Application.

You will also need to refer to or complete the following documents:

DCA Grants General Eligibility – to be eligible to apply for a DCA grant, individuals, groups and

organisations must first satisfy the general eligibility criteria outlined in this document.

DCA Grants Key Dates Calendar – this calendar lists the round open date, draft review request

deadlines, activity start dates and application closing dates for 2015.

Supplier Creation Form - complete and submit this form with your support materials to enable DCAto transfer grant funds to you.

Administered Grant Agreement Form – if this grant is being administered by a third party, the

completed form signed by both parties must be submitted along with the support materials for this

application.

Support Material “how-to” Guide – this document provides detailed instruction on how to submit

your support materials and complete the relevant section of this application form.

All documents are available for download at www.dca.wa.gov.au/online-grants

http://www.dca.wa.gov.au/Documents/Online_Grants/General_Information/DCA_Grants_General_Eligibility.pdf

http://www.dca.wa.gov.au/Documents/Online_Grants/General_Information/DCA_Grants_Key_Dates_Calendar.pdf

http://www.dca.wa.gov.au/Documents/Online_Grants/Applicant_Resources/Administered_Grant_Agreement_Form.doc

http://www.dca.wa.gov.au/Documents/Online_Grants/Applicant_Resources/Support_Material_Guide.pdf

www.dca.wa.gov.au/online-grants

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http://www.dca.wa.gov.au/Documents/Online_Grants/Applicant_Resources/Supplier_Creation_Form.pdf

http://www.dca.wa.gov.au/online-grants/online-grants-applicant-resources/program-handbooks/

http://www.dca.wa.gov.au/Documents/Online_Grants/Applicant_Resources/Guide_to_Completing_Your_Application.pdf

Applicant Details Is this grant being administered on behalf of an individual or group?

Yes No

If yes, download, complete and submit the Administered Grant Agreement Form with your

support material. Applicant details required below will be that of the administering body.

Complete the Individual applicant section of this form if the administering body is an

individual, or the Organisation section if the administering body is an organisation.

Are you applying as (tick one)? (Please complete your details on the relevant page.)

An Individual A Group An Organisation

If you are awarded a grant, a contract and payment record will be created based on the

details supplied in this grant application.

Individuals

The Application Name must match your registered Australian Business Number (ABN).

If you do not have an ABN enter your full legal name.

Application Name

Physical Address

Title:

First Name:

Last Name:

Date of birth:

Australian Business Number (ABN):

GST Registered: Yes No

Street Address:

Suburb:

State:

Postcode:

State Electorate (WA residents only – leave blank if unknown):

DCA Grants Application Form 2


Postal Address

Same as physical address:

PO Box:

Street Address:

Suburb:

State:

Postcode:

Country:

Contact Details

Equity and Evaluation Questions

Answering the following questions is optional and will not affect the assessment of your grant

application. The information you provide here will assist DCA to improve its services through

statistical research and evaluation of the equity and accessibility of grant programs.

Phone:

Mobile Phone:

Email:

Website:

Are you an Australian citizen or permanent resident? Yes No

Have you been a resident of WA for the past 12 months? Yes No

Country of Birth:

Gender:

Female Male

Are you of Aboriginal origin?

Yes No

Are you of Torres Strait Islander origin?

Yes No

Not Specified

Not Specified

Not Specified


Do you speak a language other than English at home?

Yes No Not Specified

If yes, please specify other languages spoken:

How well do you speak English?

Very well Well Not well Not at all

Do you have a disability?

Yes No Not Specified

If yes, you may choose to indicate the nature of your disability from the list below:

Physical

Sensory

Psychiatric

Neurological

Cognitive

Intellectual

Groups

Group applicants must have a current Australian Business Number (ABN) in the name of the

group.

By providing your contact details below, you are taking responsibility as the group’s key

contact for all dealings with DCA. Please ensure you have the authority of your group to

submit an application on their behalf.

Key Contact Details

Group Application Name:

Trading Name (if applicable):



Title:

First Name:

Last Name:

Role of Key Contact:


Phone:

Mobile Phone:

Email:

Physical Address

Street Address:

Suburb:

State:

Postcode:

Postal Address


PO Box:

Street Address:

Suburb:

State:

Postcode:

Country:

Organisations

Organisation applicants must have a current Australian Business Number (ABN) in the name

of the organisation.

Legal Name of Organisation:

Trading Name (if applicable):

Legal Status (e.g. Incorporated Association):



Website:

By providing your contact details below, you are taking responsibility as the organisation’s

key contact for all dealings with DCA. Please ensure you have the authority of your

organisation to submit an application on their behalf.


Key Contact Details

Title:

First Name:

Last Name:

Role of Key Contact:

Phone:

Mobile Phone:

Email:

Physical Address

Street Address:

Suburb:

State:

Postcode:

Postal Address


PO Box:

Street Address:

Suburb:

State:

Postcode:

Country:

Organisation Contact Details

Phone:

Website:


Funding Category

Program:

Program Category:

Area of Practice:

Community Arts and Cultural Development

Disability Arts

Cultural Diversity Arts

AboriginalArts

Not applicable to this application

Discipline (you may only select one discipline):

Circus

Comedy

Dance

Design

Digital Arts

Interdisciplinary

Music

Theatre

Visual Arts and Crafts

Writing

Fashion


Description of discipline (e.g. hand built raku fired ceramics):

Project Outline Project Title: 145 Character limit

(including spaces)

Project Summary:

500 Character limit (including spaces)

Project Start Date:

Project End Date:

Total Project Cost ($):

Funding Requested from DCA ($):


Where did you hear about DCA funding?

DCA Website

Newspaper

Radio

Word of Mouth

DCA Project Officer

Social Media

Previous Applicant

DCA Funding Workshop

Arts Organisation

Application Information

Activity Location

List the planned number of activities at the relevant locations below.

Western Australian Region Planned Number of Activities

Perth

Gascoyne

Goldfields - Esperance

Great Southern

Kimberley

Mid West

Peel

Pilbara

South West

Wheatbelt

Total


Y/N

Australian State or Territory (other than WA) Planned Number of Activities

Australian Capital Territory

New South Wales

Northern Territory

Queensland

South Australia

Tasmania

Victoria

Total

Country (other than Australia) Planned Number of Activities

Total

Total of all activities

If you are unsure which western Australian region your activity falls within, please refer to the

Department of Regional Development website reference map www.drd.wa.gov.au.

Key Personnel

Who are the key creative and administrative personnel involved in this project?

Note: the support materials you need to submit for key personnel will depend on the program and category you are applying to.

*Date of birth is required for applicants and/or key personnel aged 29 and under only.

Name Position/Role in project *Date of Birth Confirmed

Yes No

Yes No

Yes No

Yes No

Yes No


http://www.drd.wa.gov.au/

http://www.dca.wa.gov.au/online-grants/online-grants-applicant-resources/program-handbooks/

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Project Details What is required in your responses below will depend on the program and category you are

applying to. Refer to the program handbooks for information.

Question 1: What is the project or activity you are seeking DCA funding for?



http://www.dca.wa.gov.au/online-grants-handbooks

Question 2: What outcomes will be achieved?


Question 3: How do you plan to undertake the project or activity?



Question 4: What is the timeline for the project or activity?


Question 5: How will you evaluate the project or activity?



Question 6: What are your plans for marketing, promotion and/or distribution

for the project or activity?


Project Demographic Information Note: Your application will be assessed on the planned strategies to involve the

demographic target group you identify in each question in this section. If you do not intend

to engage any of the demographic target groups listed, please select 'Not applicable to this

application'.

Primary Target Group

What is the primary demographic target group you plan to engage in this

project or activity? (you may only choose one target group for each section)


People of Aboriginal and Torres Strait Islander origin

People with disabilities

Culturally and linguistically diverse people

People living in remote/regional areas

Young people


Early career artists

Older people

International and cultural exchange

Secondary Target Group

What is the secondary demographic target group you plan to engage in this

project or activity?






Young people


Older people


Employment Target Group

Will this project or activity employ people from one of the demographic

target groups listed below?






Young people


Older people



Financial Information

Amount of your request to DCA: $

The amount of your request to DCA will be the Total Expenditure minus the Total Income.

You are not required to complete this field as it will be automatically populated when you complete the below financial information sections. Refer to DCA Grants - A Guide to Completing Your Application for eligible expenditure items.

Expenditure

Administration Total Notes

Subtotal


Marketing, Promotion and Distribution Total Notes

Subtotal


Preparation, Development, Production and

Exhibition/Presentation

Total Notes

Subtotal


Travel and Freight Total Notes

Subtotal


Salaries, Fees and Living Allowances Total Notes

Subtotal

Total Expenditure


Income

Indicate whether the income is confirmed (C) or not confirmed (NC) in the notes for each

income item.

Earned Income Total Notes

Subtotal


-

In kind Total Notes

Subtotal


Corporate Sponsorship Total Notes

Subtotal


Philanthropic Donations Total Notes

Subtotal


Australia Council Total Notes

Subtotal


Other Federal Government Total Notes

Subtotal


Other State Government Total Notes

Subtotal


Local Government Total Notes

Subtotal


Other Income Total Notes

Subtotal

Total Income


Additional Budget Notes


Statistical Information Indicate the estimated outputs for your planned project or activity where relevant and explain your numbers in the Notes for that line item. Important: do not enter any URLs or web addresses in Notes.Note: Your responses will not be used in the assessment of your application in any way. However; if your application is successful, you will report your actual outputs against this data at the acquittal stage.

Type/Category of Work Planned

Number

Notes

New works/products

Use of existing works/products

Remounts of past productions


Creative developments

Number of Activities Planned

Number

Notes

Total number of creative developments,

performances, events, exhibitions, tours,

publications or recordings

Total number of residencies, workshops,

school programs, masterclasses, forums,

seminars or other activities

Attendance (creative developments,

performances, events or exhibitions)

Planned

Number

Notes

Total number of paid attendances

anticipated

Total number of unpaid attendances

anticipated

Total number of attendances at

free/unticketed events anticipated

Participation (residencies, workshops, school

programs, masterclasses, forums, seminars or

other activity)

Total number of paid participants

anticipated

Planned

Number

Notes

Total number of unpaid participants

anticipated


Total number of participants anticipated at

free/unticketed events

Online Engagement Planned

Number

Notes

Total number of website views anticipated

Total number of social media

comments/likes anticipated

Publications Planned

Number

Notes

Number of digital publications planned

Number of printed publications planned

Total number of publications anticipated to

be sold

Total number of publications anticipated to

be given away/distributed for promotional

purposes (no income from sales)

Sales Planned

Number

Notes

Anticipated sales from products


Anticipated sales from services

Media Coverage Planned

Number

Notes

Anticipated number of newspaper items,

articles, reviews, etc.

Anticipated number of magazine or journal

articles, reviews, etc.

Anticipated number of radio interviews,

reviews, etc.

Anticipated number of television

appearances, coverage, etc.

Anticipated number of online articles,

reviews, blogs etc.

Personnel Planned

Number

Notes

Anticipated number of full-time paid

personnel directly involved in this project or

activity

Anticipated number of part-time paid


activity

Anticipated number of casual paid


activity


Anticipated *FTE for all paid personnel

directly involved in the project or activity

(*refer to the handbook for details)

Anticipated number of volunteers directly

involved in this project or activity

Anticipated number of volunteer hours

involved in this project or activity

Applicant Feedback

Note: the information you provide here will assist DCA to improve its services. This information

will not form part of your application assessment.

Please indicate on a scale of 1 to 5 with 5 being high.

1 2 3 4 5 Clarity of the grants program information.

User-friendliness of the grant application process. 1 2 3 4 5

Overall satisfaction with the grant application process. 1 2 3 4 5

Additional Notes



Previous Funding List any funding support received in the previous three years. Also include details of funding

received through an auspice body on your behalf.

Applicant Name Funding Body Year Project Amount ($)


Support MaterialSee the DCA Grants - A Guide to Completing Your Application for support material quotas and individual item limits.

All applicants: please complete and submit a Supplier Creation Form with your support materials. This will enable DCA to transfer funds to you if your grant application is successful.

Administered grants: submit the completed Administered Grant Agreement Form with your support materials.

Office Use Only

Application Number:

Applicant Name:

Program:

Program Category:

Funding Round:

Project Title:

Title Description Office Use Only

(Include full URL address for all links) (Received)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


http://www.dca.wa.gov.au/Documents/Online_Grants/Applicant_Resources/Guide_to_Completing_Your_Application.pdf

http://www.dca.wa.gov.au/Documents/Online_Grants/Applicant_Resources/Supplier_Creation_Form.pdf


Title Description

(Include full URL address for all links)

Office Use Only

(Received)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No


Grant Application Terms and ConditionsAll applicants must read and complete this section.

Declaration

1. I have read and am familiar with the information relevant to this application as published on the Department of Culture and the Arts (DCA) website.

2. I acknowledge that this application will not be accepted if it is late, does not include all the required support material, or is subject to outstanding acquittals.

3. I am aware of my rights and responsibilities with regard to copyright and intellectual property as it relates to this project and confirm that all parties with a potential claim to copyright and intellectual ownership arising from this project have been consulted and provided their agreement where required.

4. I confirm that the supporting material submitted with this application is my own work or the work of the artists named in this application.

5. I give DCA a licence to reproduce and communicate the supporting material submitted with my application for the purposes of assessment, and confirm that I have obtained all copyright and intellectual permissions as required to do so.

6. I am not seeking funding for work that will be submitted for academic assessment.7. I agree to accept DCA’s funding decision on my application.

8. I have read and understood the section on Privacy and Freedom of Information and accept the terms.

9. I agree to inform DCA of any changes in the status or circumstances of the application between the time of its submission and its assessment.

10. I am aware that DCA reserves the right to require me to provide evidence to verify that a current Working with Children Assessment Notice is held by all relevant personnel where the activity involves working with people under the age of 18.

11. All statements in this application are true to the best of my knowledge.

Media Contact Consent

In the event that your grant application is successful, do you give the Department of Culture

and the Arts permission to pass your primary phone number and/or email address on to the

media?

Media Consent: Yes No

Working with Children

The Working with Children (Criminal Record Checking) Act 2004 makes it compulsory for

many people in child-related work to apply for a Working with Children Check. A person is in

child-related work if their usual duties or work involve, or are likely to involve:


http://www.checkwwc.wa.gov.au/checkwwc/Publications+and+Forms/Legislation.htm

Contact with a child (a child is a person under the age of 18 years); and

That contact is in connection with at least one of the 19 categories of child-related

work listed under the Act;

And no exemptions apply.

Please read Statement 1 and Statement 2 below and check the box that applies to you,

your group or organisation.

Statement 1

This activity is likely to involve personnel working with people under the age of 18.

I am/the group/the organisation is aware of the special responsibilities associated with

working with children and am aware of the Working with Children Act 2004, and will take the

necessary steps to ensure that, where required, all relevant personnel have a current Working

with Children Assessment Notice, or are able to obtain one.

Statement 2

The organisation and/or the activity does not involve working with young people aged

under 18.

Privacy and Freedom of Information

Full listings of grant recipients will be published on our website and in our Annual Report. We

may also publicize recipients in our newsletters and publications. You will be required to

acknowledge the Department of Culture and the Arts in all your publicity if your application

is successful. Failure to do so may affect your grant payment.

According to the Freedom of Information Act (1992) (the Act) any information held by us,

including your application is accessible by you. While the information you present to us is

treated as confidential, staff and external peer assessors may see it. The information you

supply may also be made available to those assessing any other grant applications you

make. By submitting your application you waive any right to raise any type of proceedings

against the Department as a consequence of, or in contemplation of, any disclosure of the

contents of your application in response to an information request made under the Act.

Data held in the Department’s system may be used for the following purposes: statistical

reporting, application assessment, media enquiries, accounting purposes and for contacting

you. The details of your grant will be public information, however, your personal details will

only be accessible by our staff, appointed auditors and individuals or organisations who may

help us assess or monitor grants.

Declaration

I have read, understood and accepted the DCA grant application terms and conditions as

outlined above.

Signature: Date:


http://www.slp.wa.gov.au/legislation/statutes.nsf/main_mrtitle_353_homepage.html