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)*

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Address*

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Postcode*

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Phone Number*

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Phone Number*

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Email Address*

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Contact Person's Name*

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Position*

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Details of Youth Requiring Financial Assistance

The number of applicants

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

Full Name of Youth (Applicant)*

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Full Name of Youth (Applicant 2)*

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Full Name of Youth (Applicant 3)*

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Full Name of Youth (Applicant 4)*

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Date of Birth*

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Date of Birth*

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Date of Birth*

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Date of Birth*

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Address*

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Postcode*

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Phone Number*

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Phone Number*

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Funds Required From Riccarton Rotary Youth Trust

Amount sought from Trust (A)

$

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(A)

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

$

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(B)

Total amount required (A + B)

$

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(A + B)

Date that funds are required by*

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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

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Please add the details

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Has the applicant sought assistance from other sources:*

Yes

No

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

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Supporting files

Invoices/quotes

File Uploads

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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*

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Bank Account Number*

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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.)

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Family / Financial

(you may be required to justify this income)

Caregivers*

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Ages of dependent children living in the household?*

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Source

Amount

Total net weekly income from all sources:

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$

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

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$

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$

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Weekly Mortgage Payment:

$

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Weekly Rent Payment:

$

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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.)

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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

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2

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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.

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

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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.

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

Full Name*

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Date:

31 October 2025

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