WORD2016 Commissions & Co-Productions Programme - Expression of Interest Application Form1. CONTACT DETAILS

Artist/Organisation:Primary Contact:Position within organisation:Address:

Tel: Fax:Email: Website:

2. SUMMARY PROJECT DETAILS

Name of proposed project:Provisional dates for proposed project:Preferred venue for project activity:Preferred venue for final exhibition/performance if applicable:

3. WORD2016 THEMES AND TARGET AUDIENCES

Please tick which of the three themes you will address with your proposed project:Older adults with dementia (65 years and over) and their familiesYoung people with mental health difficulties (specifically projects that work to improve the wellbeing of young people aged 13 – 25 years) and their familiesChildren (especially early years – 1- 5 years) and their families.

4. PROJECT BENEFICIARIES

Number of participants Age rangeHow will your reach and engage participants? (Max 250 Words)

How will participants benefit from your proposed project? (Max 250 Words)

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5. PROJECT PROPOSAL

When completing this section please make sure you refer to the criteria in the Word2016 Commissions and Co-Productions Expression of Interest Guidelines.

5.1 About You and Your Organisation (Max 250 Words)Please provide a brief summary of your work and practice and those of any partners.

5.2 Project Outline (max 1000 words) Please provide an outline summary of your proposed project

6. SUMMARY BUDGET

Please indicate all expenditure for your project and any additional income you may have received to support the delivery of your project.

Key things to remember: Your budget has to balance (your income needs to be the same as your expenditure) Please break down your figures clearly so we can see how you have worked out costs Your expenditure should be for the total cost of the activity you are applying to do Please feel free to add extra lines to the budget breakdown below (if required).

Please state the amount you are requesting from Word2016 (max grant £6,000):

EXPENDITUREExpenditure Heading Description Amount £

Total Project Expenditure

INCOMEIncome Heading Description Status:

Expected or Confirmed?Amount £

Request from Word2016

Total Project Income

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IN-KIND SUPPORTPlease describe any in-kind support you will provide (or have bring in) to deliver the project.Description Expected or Confirmed? Amount £

Total In-Kind Support

Do you wish to supply any additional information in support of your expression of interest? (Max 200 Words)

DECLARATION

By signing this form, you agree to the following:

We will use this application form and the other information you give us, including any personal information, for the following purposes.

To decide whether to commission your organisation to deliver the project described as part of the Islington Word2016 festival programme

To hold in our database and use for statistical purposes. If we offer you a commission or co-production, we will publish information about you relating to

the activity we have funded, including the amount of the commission or co-production and the activity it was for.

I confirm that the organisation named on this application has given me the authority to sign this application on its behalf.

I confirm that the activity in the application falls within the powers of the organisation's constitution or memorandum and articles of association (the legal document setting out the rules governing the organisation).

I confirm that, as far as I know, the information in this application is true and correct.

Sign…………………………………………………. Date………………………………

Please return your completed application form and any attachments to:Tony Brown, Stock and Reader Development Manager,Islington Council Library and Heritage Services, Central Library, 2 Fieldway Crescent, N5 1PFT: 020 7527 6963 E: tony.brown@islington.gov.uk

CLOSING DATE FOR COMPLETED EXPRESSIONS OF INTEREST: 12noon – 9 November 2015FOLLOW UP MEETINGS WITH SELECTED ARTISTS/ORGANISATIONS will be held on 26 or 30 November 2015

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