Application

Application Form

What you will need before you start:

Details of your organisation and the applicant you are applying for
How much funding you require and how much the applicant will be providing
Bank account details where funds are to be paid if the application is successful.
Please note we are unable to pay funds directly to the applicant or their family
Scans or photos of supporting documents such as invoices or quotes
Applicants home situation (Caregivers, dependents)
Applicants family financial details (income and mortgage/rent payments)
2 Referees - one of whom should be a responsible person independent from the family and the organisation submitting the application. (eg: teacher, budget advisor, doctor, counsellor, church leader, social worker or the like)

Details of Organisation Submitting the Application

Name of Organisation (Organisation)*

Invalid Input

Address*

Invalid Input

Postcode*

Invalid Input

Phone Number*

Invalid Input

Phone Number*

Invalid Input

Email Address*

Invalid Input

Contact Person's Name*

Invalid Input

Position*

Invalid Input

Details of Youth Requiring Financial Assistance

The number of applicants

Invalid Input

(you can include up to 4 applicants on this form)

Full Name of Youth (Applicant)*

Invalid Input

Full Name of Youth (Applicant 2)*

Invalid Input

Full Name of Youth (Applicant 3)*

Invalid Input

Full Name of Youth (Applicant 4)*

Invalid Input

Date of Birth*

Invalid Input

Date of Birth*

Invalid Input

Date of Birth*

Invalid Input

Date of Birth*

Invalid Input

Address*

Invalid Input

Postcode*

Invalid Input

Phone Number*

Invalid Input

Phone Number*

Invalid Input

Funds Required From Riccarton Rotary Youth Trust

Amount sought from Trust (A)

$

Invalid Input

(A)

Amount to be contributed by applicant and/or family (B)

$

Invalid Input

(B)

Total amount required (A + B)

$

Invalid Input

(A + B)

Date that funds are required by*

Invalid Input

Please Note

The Committee meets on the 3rd Tuesday of each month. Applications must reach the Secretary one week prior to the meeting. Applications received after the cut-off time may be held until the next meeting.

Has the applicant sought assistance from RRYT before:*

Yes

No

Invalid Input

Please add the details

Invalid Input

Has the applicant sought assistance from other sources:*

Yes

No

Invalid Input

If so, list where funds have been sought from / contributed. What was the outcome?

Invalid Input

Supporting files

Invoices/quotes

File Uploads

Invalid Input

You can upload up to 5 files
They must be under 5MB
You can upload JPEG, PNG or PDF files

Bank Account Details

Please Note: Payment cannot be made directly to the applicant or their family

Bank Account Name*

Invalid Input

Bank Account Number*

Invalid Input

Purpose of the Grant

(Set out what the funds will be used for, who will benefit, how it will be achieved and how success will be measured.)

Invalid Input

Family / Financial

(you may be required to justify this income)

Caregivers*

Invalid Input

Ages of dependent children living in the household?*

Invalid Input

Source

Amount

Total net weekly income from all sources:

Invalid Input

$

Invalid Input

(Please list and include benefits, wages, accommodation support etc)

Invalid Input

$

Invalid Input

$

Invalid Input

Weekly Mortgage Payment:

$

Invalid Input

Weekly Rent Payment:

$

Invalid Input

Supporting Statement from Organisation Submitting the Application:

(This statement should set out why you support the application, your general assessment of the family and any other information you feel would support the application.)

Invalid Input

Names, addresses and phone numbers of 2 referees from whom the Trustees may obtain a confidential report:

**ONE OF WHOM SHOULD BE A RESPONSIBLE PERSON, INDEPENDENT FROM THE FAMILY AND THE ORGANISATION SUBMITTING THE APPLICATION**
(eg: Teacher/Budget Advisor/Doctor/Counsellor/Church Leader or the like)

1

Invalid Input

2

Invalid Input

Terms & Conditions

Please check the following terms and conditions to indicate you have read and agree with them.

In accordance with the Privacy Act, I give the Riccarton Youth Trust permission to share the information in this form with another agencies and/or referees, in order to verify its correctness.

Invalid Input

I declare the information in this application is, to the best of my knowledge, accurate and correct.

Invalid Input

I declare that I (or a responsible member of my organisation) have met and interviewed the applicant and have gathered sufficient evidence to support this application.

Invalid Input

Please type in your full name as the Contact person from the organisation submitting the application

Full Name*

Invalid Input

Date:

16 October 2024

Riccarton Rotary Youth Trust

Supporting Children and Young People in Need

Riccarton Rotary Youth Trust Application

Application Form

What you will need before you start:

Details of Organisation Submitting the Application

Details of Youth Requiring Financial Assistance

Funds Required From Riccarton Rotary Youth Trust

Supporting files

Purpose of the Grant

Family / Financial

Supporting Statement from Organisation Submitting the Application:

Names, addresses and phone numbers of 2 referees from whom the Trustees may obtain a confidential report:

Terms & Conditions