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Bridge House Estates Trust Fund Charity Registration Number_ 1035628_

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Bridge House Estates Trust Fund Charity Registration Number_ 1035628_ Powered By Docstoc
					LC REF:                                                                                                   45 Westminster Bridge Road
Date                                                                                                           London SE1 7JB
Received:
                                                                                                              Tel: 020 7021 4204
Acknowledged:
                                             SAMARITAN GRANT                                              london.catalyst@peabody.org.uk
                                             APPLICATION FORM
                              BEFORE COMPLETING PLEASE READ THE ATTACHED GUIDANCE

1       ABOUT YOUR ORGANISATION
Name &
Department:
Correspondence
Address:


Postcode:
Charity Number:                              Circle Type
(if applicable)                              of Agency:       NHS Trust/SW Team/Church/Vol. & Community Organisation/Other……………….


2       AIMS AND ACTIVITIES (you may use bullet points to summarise)
What are your current activities/services? Who do you work with? How many people do you assist each year?




3       ABOUT YOU AND THE GRANT ADMINISTRATION
Detail below the person who will be the main contact responsible for administering the grant and a second person who will either
deputise for, or line manage, the administration of the grant.
Main Contact :                                                                         Position:
(Title, forename, surname)
Tel:                                                   Fax:                                  E-mail:

Second Contact:                                                                              Position:
(Title, forename, surname)
Tel:                                                   Fax:                                  E-mail:



4      FUNDING
(a) If you currently receive a Samaritan Grant please complete:
Date Received        Amount                    Current Balance            Date expected to use by        Monitoring Report Submitted?
                     £                         £                                                         YES/NO
(b) If you have not received a Samaritan Grant before or are reapplying please complete:
Amount Requested                What will the Fund be used for?
£




(c) If successful, to whom should the cheque be made payable?:
Account Name
                     Account Number                        Bank                                               Sort Code
   TO ASSIST OUR MONITORING PLEASE TICK ONE BOX IN EACH OF THE FOLLOWING CATEGORIES

5            WHO ARE YOUR MAIN CLIENTS?
Children/Young people                Adults             Older People                      Families             Other:


6            DETAILS OF YOUR CLIENTS:
Long term limiting or debilitating illness or condition                                       Dual Diagnosis (LD/MH)

Terminal/life threatening illness or condition                                                Dementia

Physical disability                                                                           Unpaid carer for a sick, elderly or disabled person

Learning disability/difficulties                                                              Drug, alcohol, other substance dependent

Mental ill health                                                                             Multiple health & social needs

Other health problem                                                                          Emotional distress (e.g. bereavement)

Other:



7            FURTHER DETAILS:
Homeless (inc: temporary accommodation)                                                       Low income/living in poverty

8            ETHNIC GROUP If no single category reflects all your users add a % in the appropriate box to indicate your main user group
White British                   Indian                    Other Asian background                     Other Black background            Other Minority Ethnic
                                                                                                                                       Group
White Irish                     Pakistani                 African                                    Chinese

Other White                     Bangladeshi               Caribbean                                  Mixed Heritage                    No Majority Ethnic
background                                                                                                                             Group
9            REFUGEE OR ASYLUM SEEKERS                                      No              Yes           Country of Origin

10           IN WHICH LONDON BOROUGH DO YOU MAINLY OPERATE?
Barking &                 Ealing                                Havering                                   Lewisham                       Tower Hamlets
Dagenham
Barnet                    Enfield                               Hillingdon                                 Merton                         Waltham Forest
Bexley                    Greenwich                             Hounslow                                   Newham                         Wandsworth
Brent                     Hackney                               Islington                                  Redbridge                      Westminster
Bromley                   Hammersmith & Fulham                  Kensington & Chelsea                       Richmond/Thames                City of London
Camden                    Haringey                              Kingston upon Thames                       Southwark                      London-wide
Croydon                   Harrow                                Lambeth                                    Sutton
London Catalyst           IMD (2004) Rank,
OFFICE USE                Domain other details


11           DENOMINATION - FOR CHURCH & FAITH GROUPS ONLY
             Anglican                                Orthodox                             Sunni                         Hindu
 CHRISTIAN




             Other Protestant                        Reform                               Shi’ite                       Sikh
                                                                                 MUSLIM
                                            JEWISH




                                                                                                               OTHER




             Roman Catholic                          Other                                Sufi                          Buddhist
             Other                                                                        Other                         other


MULTI-FAITH ORGANISATION


 12 YOU MUST ENCLOSE THE FOLLOWING DOCUMENT WITH THIS FORM
 A copy of your most recent ACCOUNTS and ANNUAL REPORT or, if an NHS Trust, Social Services or other Public
 Body, a copy of your department’s service literature.

                                                                       DECLARATION
   When you have read the guidance, completed the form and included the information requested please sign below
To the best of my knowledge, all the information I have provided on this application form is correct and I have
the authority to sign this request on behalf of the organisation/department.
SIGNED:                                                                                                                        DATE

NAME:                                                                                                          POSITION
(please print)
                               SAMARITAN GRANT GUIDANCE

    What is the Samaritan Grant Scheme?
1   A grant scheme run by London Catalyst (formerly the Metropolitan Hospital-Sunday Fund)
    which makes block grants to help people in need for use by:
       o Social and Health Service community teams and NHS Hospital social work teams
       o Church Ministers & Diocesan offices
       o Approved voluntary and community organisations
2
    What is the aim of the scheme?
    To provide an emergency fund to assist advice workers, social workers and health
    professionals giving help at critical times to clients who have immediate personal needs that
    cannot be met from statutory sources.
    We also hope to learn more about the impact of our grant making. The monitoring of grants
    is, therefore, important to us.
3
    Who can we help?
    Those in severe need, in particular people whose personal circumstances are limited by
    physical and mental ill health, disability or personal crisis. Hospital in-patients and people
    living in the community can also be assisted. All beneficiaries must be on a low income and
    have no access to alternative public and private funds.
4
    What can we use the fund for?
       o Essential clothing and footwear
       o Household items: appliances and equipment such as cooking utensils, crockery, bed
         linen and towels
       o Essential repairs and decoration to make accommodation habitable
       o Special items of equipment and services not available from statutory sources
       o Respite breaks
       o Fares and travelling expenses, within UK only, including hospital treatment attendance
         or appointments related to treatment
       o Vocational training short courses and equipment
       o Transitional child care (one-off payments, time limited to a maximum of 2 weeks)

    The Trustees recognize the value of responding to need on a case by case basis. If there is
    any uncertainty as to whether or not the request is eligible you can contact the London
    Catalyst Office for confirmation.
5
    What the fund must NOT be used for:
       o Items and services it is the duty of a statutory agency to provide or if public funding
         exists for their provision
       o Holiday breaks outside the UK (unless a compelling reason exists)
       o Debts, arrears, fees or contracts (including credit cards, utilities and rent deposits)
       o Funeral expenses
       o Alcohol, cigarettes and any other addictive substance
6
    How much can we ask for?
    Grant funds are limited. Base your request on your team’s past use of the scheme and
    experience of demand in severe cases. If applying for the first time, request a realistic figure
    that matches your experience of working with clients in the greatest need. This will help you to
    be clear about how you will target the use of the grant and enable you to administer the grant
    effectively.
     There is no guarantee that the full sum requested will be awarded in all cases. We anticipate
     that most block grants will be in the range of £500 to £3,000 per annum.

7
     How much can we give out?
     You will have the discretion to make grants of up to £250 to an individual client.
     In some cases, where there is severe need, we may authorise grants above this level, but
     requests over £250 must be referred to the London Catalyst office.

8
     How do we apply for a grant?
     Complete the attached application form and return, with enclosures, to the London Catalyst
     office. We will then contact you to verify some details. Applications are usually considered at
     the beginning of each calendar year, although some new applications will be considered at
     the Trustee’s quarterly meetings throughout the year.

9
     How does the Scheme operate?
     Before applying discuss the idea with your colleagues. If successful you must nominate
     someone within the team, and a deputy, to administer the grant – this could be the team
     manager, a social worker, a team administrator, welfare officer, finance officer or secretary.
     Paperwork is minimal but record keeping is essential. You must keep proper records to
     account for how money is allocated in line with our grants criteria.

10
     Records & Reporting
     Records must be kept (we will send a simple individual record format which can be
     photocopied and adapted as required). We will also ask you to complete a London Catalyst
     block grant monitoring form.

     The monitoring form is important and must be completed and returned to London Catalyst
     within twelve months or when the grant has been used in full. We will conduct periodic
     monitoring visits.

     If reapplying you can do so whilst still holding a balance of funds not greater than 15% of the
     original grant but you must provide a monitoring report. No future applications can be
     considered until the completed monitoring form is returned to London Catalyst.

     FOR FURTHER INFORMATION
     If you are unsure whether or not a particular request meets our criteria, or wish to discuss
     your application please contact the London Catalyst team on

                                           020 7021 4204

                                        London Catalyst ,
                                   45 Westminster Bridge Road,
                                        London SE1 7JB

                                    www.londoncatalyst.org.uk

				
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