Sport NZ Rural Travel Fund Application Form

Are you registered for GST?

(Required)

Yes
No

If yes, please type in your GST Number

How much money are you applying for? - Sport NZ funding

How much money are you applying for? - Other funders

Your contribution

TOTAL

If you have applied for funding from other organisations please supply details

Write down all the costs of your project and include the details, eg materials, venue hire, promotion, equipment hire, artist fees and personnel costs.

Organisation - (including other councils)	Amount requested ($)	Results date (if known)
-	-	-
-	-	-

Alternatively you can attach this information in the 'Supporting' Details section.

Do you have endorsement from your local affiliated club/school for this application for funding?

(Required)

Yes
No

If yes, briefly explain
Attach the evidence below within the 'Supporting Details' section.

Name of organisation (Required)
Contact person (Required)
Postal address (Required)
PO Box address
Phone (Required)
Email (Required)

1st Contact Name
1st Contact Number
2nd Contact Name
2nd Contact Number

Are you a club or a school? (Required)	Club School
How many members belong to your club/school? (Required)
How many participants aged between 5 & 18 will this travel subsidy benefit? (Required)
How many participants are aged between 5-11 yrs (Required)
How many participants are aged between 12-18 yrs (Required)
Please detail how many applicants are female (Required)
Please detail how many applicants are male (Required)
Does your application involve a partnership with a local school / club (Required)	Yes No
What is this funding going to be used for? (Briefly explain) (Required)
Do you have any disabled individuals who are being supported by this fund? (Required)	Yes No
If yes, how many will receive support from the RTF
What percentage of your members live in the vicinity of the local authority you are applying to for the rural travel fund? (Required)

Declaration (Required)	We hereby declare that the information supplied here on behalf of our organisation is correct? We consent to Mackenzie 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 Signing authority (Required)
1. Position in organisation / title Signing authority (Required)
1. Date Signing authority (Required)
2. Name Signing authority (Required)
2. Position in organisation / title Signing authority (Required)
2. Date Signing authority (Required)

Supporting documents Please provide the following details Latest financial statements from your organisation (i.e., P&L, financial statement) A deposit slip (in case your application is approved) Evidence of your endorsement from your local affiliated club/school (if required) Please upload in either PDF, PNG or JPG formats.
Please attach	Latest financial statements from your organisation (i.e., P&L, financial statement) A deposit slip (in case your application is approved) Evidence of your endorsement from your local affiliated club/school (if required)
Final Checklist	Have you answered every question? Have you attached the relevant documents with your application?

Sport NZ Rural Travel Fund Application Form

Details

Contact Names

Organisation Details

Financial Details

Declaration

Supporting Details

Privacy Statement

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