Community Champion Programme
Expression of Interest to be a host organisation 

Applicant Details

Name of organisation: __________________________________

Name of lead contact:  ________________________________

Address: _____________________

Post Code : ___________________

Telephone No: _________________

Email Address: 

Declaration of Interest
Please tell us whether any Liverpool City Council (LCC) employee or councillor undertakes any official role in your organisation or has a financial interest in your organisation

Name of person	Councillor or employee?	Role in organisation	

			

About your organisation 
Does your proposal primarily relate to work with BAME Communities? 
People with disabilities?  Please tick

What is the current purpose and main activities of your organisation including existing or previous community engagement with BAME communities and / or people with disabilities? 

Limit to 500 words 

	

Legal Status of your Organisation	

Company Reg. No:                           Charity Reg. No:

Organisation legal status:
	Company Limited by Guarantee without shares		
	Community Interest Company without shares		
	Industrial Providence		
	Friendly society		
	Unincorporated Association		
	Charitable Incorporated Organisation		
	Social Enterprise		
	Other (please state):		

General information 

1. How long has the Organisation / Group been formed?	

2. Do you have governing documents    	Yes 	No 

3. Details of any previous relevant work with LCC or other local authorities or public sector organisations - Please also provide any contact details

	

4. Please describe your proposal to be a host organisation for the Community Champions programme. 

Limit 500 words 

	

Finance	

5. Financial Details (please state amount and source)

Project Cost:		___________________

Funding applied for:	____________________

6. Do you have a bank account in the name of your organisation?

Yes   (how many years?)            No 

7. Are you or have you previously been in receipt of Grant Funding or have an existing service level agreement with the Council? 

Yes 	 No 

If ‘yes’ how much and what for?

	

Policies

Please indicate whether you currently have the following policies in place, at this stage we do not need copies.

Equal Opportunities Policy 	  			Yes 	No 
Complaints Policy 					Yes  	No 
Health & Safety Policy					Yes  	No 
Financial Control Policy				Yes 	No 
Safeguarding adult and children Policy 		Yes  	No 
Environmental policy					Yes  	No 	
Volunteers Policy          				Yes  	No 	

Signed:	

Position Held:	____________________________

Dated:     ___________________________________

Please return this completed form to: communitychampions@liverpool.gov.uk

Closing date is 1st March 2021  
NB. Please retain a copy of this form for your records and should your circumstances or contact details change then please let the appropriate contact officer know. This information will be held in accordance with the Data Protection Act 2018.