Under $5000 Application Form

This document is an application form for organizations seeking sponsorship under $5000. It includes sections for organization details, contact person information, GST information, proof of incorporation, bank account details, eligibility criteria, project title, sponsorship type, project description, key activities, project reach, priority populations, message promotion, marketing strategies, co-sponsorship details, budget information, and applicant's declaration.

UNDER $5000 APPLICATIONFORM
PARTA-ORGANISATIONINFORMATION
A.1 ORGANISATION DETAILS
OrganisationName(Legalname):
TradingAsNames(ifapplicable):
Addressforcorrespondence:
Postcode:
Websiteoforganisation/
project/event(asmostapplicable):
A.2 CONTACT PERSON
Title(Mrs,Ms,Miss,Mr,Dr,Profetc):
FirstName:
LastName:
Position:
E-mail:
Mobile: Fax:
TelephoneWk: TelephoneHm:
A.3 GST INFORMATION
AustralianBusinessNumber(ABN):
(IfnoABN,pleasecompleteandattachanAT
O'StatementbySupplierForm'– ifeligible)
IstheorganisationregisteredforGST
?
(IfyourorganisationisregisteredforGST,
Healthwaywillgross-
uptheapprovedsponsorshipforGSTliabilit
y upontheissueofaRecipientCreatedTaxI
nvoice).
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A.4 PROOF OF INCORPORATION OF THE ORGANISATION
Istheorganisation:
IncorporatedundertheAssociationsIncorporationACT1987?
ACompany(e.g.PtyLtdundertheCorporationsAct2001)
AStatutoryBody(e.g.School,PublicHealthUnit,LocalGovtetc)
NB:IftheorganisationisnotoneoftheabovepleasecontactHealthwaytodetermineeligibility.
A.5 BANK ACCOUNT DETAILS
NameofAccount:
NameofInstitution:
BSB: AccountNumber:
A.6 PUBLIC LIABILITY
Organisationsarerequiredtomaintainaminimumof$5mofpublicliabilitycoverfortheperiodoftheproject.
What is the leave of public liability cover? $
A.7 ELIGIBILITY CRITERIA
Please check each box to confirm whether your organisation meets the specific eligibility criteria below. If your application does not fulfil all of the
criteria please contact Healthway on 9476 7000 to discuss whether you are eligible to apply.
Your organisation is an association, a company or a statutory body.
Your organisation is not, and is not a member of, or affiliated with, an association, governing body or regulating authority which,
directly or indirectly, is in receipt of tobacco sponsorship or funding in any manner whatsoever.
Your organisation has complied with all of its obligations under any previous Healthway funded program(s).
Your organisation will maintain a general public liability insurance policy of at least $5,000,000 for the period of this
sponsorship.
You organisation will comply with all Western Australian and Commonwealth of Australia laws which may apply to this
sponsorship (for example, the Working with Children (Criminal Record Checking) Act 2004 (WA), the Liquor Control Act 1988
(WA), the Privacy Act 1988 (Cth), the Freedom of Information Act 1992 (WA) and the Financial Management Act 2006 (WA)).
Your organisation is not a school applying for an activity that is part of the core curriculum.
Your organisation does not seek sponsorship solely for capital works, major equipment, fundraising or purchase of
infrastructure costs associated with running an organisation.
Your organisation does not seek sponsorship for interstate or overseas travel and tours, or activity occurring outside Western
Australia.
Your organisation does not seek sponsorship for project(s)/event(s) which involve a) the advancement or promotion of a
religion or religious outlook or the recruitment of people to a religion or b) the advancement or promotion of a political
organisation or political outlook.
Your organisation does not seek sponsorship for conferences, publications, and personal playing equipment, unless they are
clearly part of a wider project.
Your organisation does not seek sponsorship for boxing or any activity that allows the deliberate targeting of the head within
the rules.
Your organisation can supply an ABN or completed ATO 'Statement by a Supplier’ form.
Your organisation has appropriate Health and Safety Policies and guidelines to deliver the project/event.
Your organisation has appropriate Risk Management policies and guidelines or an expertly certified Risk Management plan in
place to deliver this event.
If required by Healthway, your organisation will maintain an expertly certified risk management plan in respect of this
sponsorship.
Your organisation can comply with the Minimum Health Policy Requirements for Sponsored Organisations
You are able to provide Exclusive Naming Rights to your project(s)/event(s)
You have read the Sponsorship Guidelines
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PARTB-GENERALSPONSORSHIPINFORMATION
B.1 PROJECT TITLE
Pleaseprovidethetitleoftheproposedproject(s)/event(s):
Title Summer Concerts in the Park
B.2 SPONSORSHIP TYPE
Whattypeofsponsorshipisbeingsoughtfortheproject(s)/event(s):
Sports
Arts
CommunityEvents
B.3 PROJECT DESCRIPTION
Pleaseprovideabriefoverallsummaryoftheproposedproject(s)/event(s):
Summary City of Nedlands has arranged various musical, food trucks and kids activities programmes for
four Sundays in the February 2019. On the 3 February the programme will be held at the Lawler
Park, Floreat where Adam Hall & The Velvet Playboys will be performing. It will be a musical
programme where various other renowned artists will be present. On 10 February it has been
arranges at the Mason Gardens, Dalkeith where Monty Cotton & The Threads will be performing
rock & roll musical shows. In the third Sunday of February the programme is arranged at Allen
Park, Swanbourne and the main attraction of that day is the female band Velvet Amps with their
mesmerising musical performances. On the last Sunday of February the programme is arranged
at Dot Bennet Park, Nedlands where the band Hi-NRG will be performing their electrifying
musical performances. In all these places and all the days of event, kids and energetic music and
food lovers will be gathering to enjoy the musical shows.
B.4 KEY ACTIVITIES
ToassistHealthwaywiththeongoingmanagementofthesponsorship,pleaseindicateonthetablebelow(orasanappendixinyourapplication)thedatean
dlocationofactivitiesforwhichsponsorshipissought:
ProjectStart 3 February, 2019
ProjectFinish 24 February, 2019
KeyActivity1
Description Musical show of Adam Hall and the Velvet Playboys
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Location Lawler Park, Floreat
ActivityStart 5.30 pm
ActivityFinish 7 pm
KeyActivity2
Description Musical Performance of the band Monty Cotton and The Threads
Location Mason Gardens, Dalkeith
ActivityStart 5.30 pm
ActivityFinish 7 pm
KeyActivity3
Description Band performance of a female band Velvet Amps
Location Allen Park, Swanbourne
ActivityStart 5.30 pm
ActivityFinish 7 pm
KeyActivity4
Description Band performance of the band Hi-NRG
Location Dot Bennet Park, Nedlands
ActivityStart 5.30 pm
ActivityFinish 7 pm
Ifrequired,pleaseprovidebriefcommentarythatmayassistHealthwayinunderstandingthedataprovided:
Commentary
Isthisanewproject(s)/event(s)? (i.e.hasnotpreviouslybeenundertaken)
Yes
No
In the following table please list the specific location(s) where project(s)/event(s)willbeheld:
LocationCategory SpecificLocations
(Listamaximumo ffivelocations only in each category )
RemoteCommunity(s)
(Anisolatedlocationwithapopulationofgenerallylessthan200) Mason Gardens, Dalkeith
RuralCommunity(s)
(Locationsoutsideofthe metropolitan area
andregionalcentresandthatarenotremote locations)
Lawler Park, Floreat
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RegionalCentre(s)
(Includes:Albany,Broome, Bunbury, Busselton,
Geraldton,KalgoorlieandMandurah)
Dot Bennet Park, Nedlands
PerthMetropolitanAreas Allen Park, Swanbourne
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B.5 PROJECT REACH
Healthway is interested in how many people will be involved in the project(s)/event(s) and how many people it will reach, particularly those
in our priority groups.
In the case of organisations that are seeking sponsorship for a range of different project(s)/event(s) figures should be aggregated.
Participants:includesallpeoplewhowillactivelyparticipateinasponsoredprogram/event.
Audience/Spectators:peoplewhospecificallycometowatchthesponsoredproject/
eventandarenotinvolvedasparticipantsororganisers.Pleasedonotincludepeoplewatchingtheactivitiesontelevisionor via social media.
Pleasecompletethefollowingtablewiththeanticipatednumbersofparticipantsandaudience/spectators*:
Participants Audience/Spectators
Male Female Male Female
Children12andunder 4 7 84 92
Youth13– 17 2 5 110 142
Adult18– 54 6 8 10245 12650
Senior55andover 4 1 3412 2125
*Anticipatednumbersshouldonlyincludethenumberofindividualsparticipating in or specifically attending towatch
theproject/event.Eachparticipant,audiencememberorspectatorshouldonlybecountedonce.Theanticipatednumbersshouldnotincludemultipleexp
osuresthatanindividualhastotheproject/event.
Theanticipatednumbersprovidedwillformpartoftheevaluationandacquittalreportcompletedforthesponsorship.
Will the project(s)/event(s) result in multiple exposures to the total population? (e.g. multi-week program to the same audience)
Yes
No
Howdidyougeneratethetotal?
Current members/participants
Marketresearch
Previousorsimilarproject(s)/event(s)
Estimated
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B.6 PRIORITY POPULATIONS
Healthwayhasidentifiedthefollowinga s prioritypopulationgroups:
● Youngpeopleandchildren(peopleaged17yearsorunder).
● Indigenouspeople(peopleofAboriginalorTorresStraitIslanderdescent).
● Ruralandremotecommunities(peoplelivingoutsidethePerthmetropolitanareaormajorregionalcentre).
● Disadvantagedgroupswhereinequalitiesexist(includingeconomic,social,educationalorculturaldisadvantage).
Pleasecompletethefollowingtablewiththeanticipatednumberofbothparticipantsandaudience/
spectatorsfromHealthwayprioritypopulationgroups:
Youngpeopleandchildren
Indigenouspeople
Ruralandremotecommunities
Disadvantaged groups
PARTC-Message Promotion (Naming Rights)
Exclusive Naming Rights is a minimum requirement of the Healthway Under $5,000 sponsorship program. By granting Naming Rights you agree that
the health message allocated by Healthway will be contained in the title and logo of the project(s)/event(s), as the first part of the title, and exclusive of
all other sponsors. No other sponsor can be allocated Naming Rights, Principal Partner or Presenting Partner.
The health message will appear in conjunction with the name of the sponsored event/activity in all signage, publications, advertisements, online
promotions, media announcements, ticketing, or any other communications promoting the event/activity undertaken by the sponsored organisation
C.1 MARKETING
Indicate below whichofthefollowingmarketingmethodsthatwillbeusedbyyourorganisationtopromotetheproject(s)/event(s):
Program advertising P/AAnnouncements
Website Project/Eventsignage
Television Advertisingflyers
Radio Ambassadors/Mentors
Newspaper Other
Please provide details of the above and
any other marketing strategies: Attractive advertising flyers will be prepared and distributed much before the
programmes.
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C.2 CO-SPONSORSHIP
Pleaseproviderelevantparticularsastoanysponsorshiporsupport(monetaryorotherwise)thatmayresultinthepromotionofalcohol,foodordrinkproducts
inassociationwithanyactivitiesoftheapplicantorganisation:
Alcohol, food
or drink
sponsors/
support
Lottery west
PARTD–BUDGET INFORMATION
D.1 REQUESTED FUNDING
Pleaseprovidethefollowingbudgetparticulars,exclusiveofGST:
Totalcostofproject/event: $ 65,000
TotalrequestedfromHealthway: $ 5,000
Note:Organisationswillberequiredtoacquitthesponsorshipfundsviaabriefacquittalreportwhichincludesanevaluationoftheevent(s)/
project(s)andsupportmaterial(i.e.photographicevidence,statementofparticipantnumbers).
PARTE-APPLICANT'SDECLARATION
STATEMENT OF CONTENT AND SOLVENCY
TheApplicantrepresentsanddeclaresthatthisapplicationforsponsorshipdoesnotcontainanyfalseormisleadingclaimorstatement.TheApplicantrep
resentsanddeclaresthattheorganisationissolventinthatitiscapableofpayingitsdebtsasandwhentheyfalldue.TheApplicantagreestothefollowingund
ertakingsandconditionsaspartofyourcontractwithHealthway:
● NottodoorallowanythinginconnectionwiththesponsoredprogramthatmaydamageoradverselyaffecttheimageofHealthwayorthatmayinfring
ethecopyrightorintellectualorindustrialpropertyrightsofHealthway.
● ToinvitearepresentativefromHealthwaytovisitthesponsoredevent.
● TousethesponsorshipfortheapprovedpurposeonlyortoseekapprovalfromHealthwayforanychangesrelatedtothesponsorship,incl
udingchangestothebudget.
● Toreturnunspentmonies.
● Toprovide,withinfourweeksoftheproject/eventcompletionabriefacquittalreportwhichincludesanevaluationoftheevent(s)/
project(s)andsupportmaterial(i.e.photographicevidence,statementofparticipantnumbers).
● Healthwayhastherighttoterminatethisagreementifthesponsorshipisnotcarriedoutaccordingtotheagreedproposalortheconditionsoutline
dabove.
● Intheeventoftheagreementbeingterminated,torepayanypartofthesponsorshipthathasnotbeenspentforanauthorisedpurposeorotherw
iseremainsunused.
● ToinvitearepresentativefromHealthwaytovisitthesponsoredevent.
● TousethesponsorshipfortheapprovedpurposeonlyortoseekapprovalfromHealthwayforanychangesrelatedtothesponsorship,incl
udingchangestothebudget.
● TheApplicantrepresentsanddeclaresthattheorganisationissolventinthatitiscapableofpayingitsdebtsasandwhentheyfalldue.
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IftheorganisationisregisteredforGST,thentocomplywithGSTrequirements,theorganisationagreesthat:
a. HealthwaywillissueRecipientCreatedTaxInvoices(RCTIs)inrespectofthesponsorshipwhereappropriate;
b. ItshallnotissuetaxinvoicesinrespectofthesponsorshipwhereHealthwayhasgeneratedaRCTI;
c. AtthetimeofenteringthisagreementtheorganisationisregisteredforGSTandHealthwaywillbenotifiedimmediatelyifGSTregistrationceas
es;and
d. ItwillremittheGSTliabilityonthesponsorshiptotheAustralianTaxationOffice.Theorgani
sation/recipientmustindemnifyHealthwayagainst:
1. alllosses,includingdamages,compensationandcosts,claimedfromoractuallyincurredbyHealthway;
2. anyandallliabilitiesallegedagainstHealthwaybyathirdpartyinrespectofbodilyinjuryordamagetopropertysustainedorallegedtobesustainedbyat
hirdparty;and
3. allcostsactuallypayablebyHealthwaytoitsownlegalrepresentatives(whetherornotunderacostsagreement)andotherexpensesincurr
edbyHealthwayinconnectionwithademand,action,arbitrationorotherproceeding(includingmediation,compromise,outofcourtsettle
mentorappeal)onanindemnitybasisandwithoutregardtoanyscaleofcosts,inconnectionwith,arisingfromorassociatedwithany:
a. breachbytheOrganisation/RecipientofobligationsunderthisSponsorship/ProjectAgreement;or
b. act,errororomissionbytheOrganisation/Recipient,itsemployeesandagentsinrespectoftheSponsorship/Project.
SIGNATURE OF APPLICANT:
---------------------------------------
POSITION: Recreation Officer
---------------------------------------
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