Smokefree Community Activation Grant Step 1 of 5 20% Activation name(Required)Applicant name(Required)Enter the key contact name for this activation. First Last Organisation or group name(Required)Email(Required) Phone(Required)Date of activation(Required)If your activation is run over a number of days please tell us your start date and all the dates you intend to deliver the Kaupapa.Time of activation(Required)Please indicate the start and end times of your event.Location of the activation(Required) Street Address Address Line 2 City Region Activation summary(Required)Describe the activities and intentions of your kaupapaWhat is the smokefree message for your kaupapa?(Required)How will you deliver on these messages?(Required)Have you as an individual or a group been the recipient of a community activation grant before?(Required) Yes No As a second time grant recipient it is a requirement that your event intends to raise quit attempts among your community. Please share how you plan to achieve this.(Required)How will you track and report the number of quit attempts raised as a result of your activation?(Required) Who is the intended participant for your event?(Required) Māori Pasifika Young People/Taiohi Hapū Māmā Disabilities Mental Health How is your event tailored to engage with these communities?(Required)Is your local stop smoking service provider going to be present at your activation?(Required) Yes No If no, are you needing support to connect with them? Yes No Who are you collaborating/working with to deliver this activation and how are they contributing?(Required)(resources/funding/delivering)How many people do you expect to reach through your activation?(Required)Please enter a number from 0 to 100000.How will you continue to promote Smokefree messages after the event?(Required)Do you wish to request the use of SF/Hāpai event equipment? (Equipment is subject to availability.)By selecting any of the equipment below you agree to the below terms. Gazebo Flag banners Pull up banner Terms for equipment requests We kindly ask that while you are in possession of the resources provided you ensure that these items are kept in good condition and used only for their intended purpose. Any damage, loss, or misuse of the resources will be the responsibility of the recipient, and you may be required to cover the cost of repairs or replacement. Budget worksheet Please outline how you plan to allocate your grant funding. Detail each item and it’s cost. (i.e. Kai for volunteers - $500) Use as many or as few of the cost item lines as required.Item 1CostItem 2CostItem 3CostItem 4CostItem 5CostItem 6CostItem 7CostItem 8CostItem 9CostItem 10CostItem 11CostItem 12CostTotal DeclarationConsent(Required) I confirm that I am authorised to submit this application on behalf of the organisation, and that our directors and/or trustees and/or treasurer are aware of and support this submission. (leave blank if not applicable)(Required)Consent(Required)Download Community Activation Guidelines 2022 I have read the “Community Activation Guidelines 2022”.(Required)Consent(Required) I confirm that information in this application is correct, and that any amount we receive as a result of this application will be used solely for the purposes specified in this application(Required)Consent(Required) I declare that we/the organisation in application do not receive funding from Health New Zealand Te Whatu Ora – Tobacco Control.(Required)Upload any supporting documentationDocuments could include proposal, poster designs etc. Drop files here or Select files Accepted file types: jpg, png, pdf, zip, Max. file size: 150 MB. How did you hear about the Smokefree Community Activation Grant?(Required) Word of Mouth Stop smoking service Other
