Please register your interest to lodge an application with the Heart Foundation Local Government Awards Coordinator in your state/territory. Refer to the ‘2016 Entry Information’ document for contact details.

IMPORTANT: Use the Application Information Pack to assist you with your application. This is available from your Local Government Awards State Coordinator, or visit www.heartfoundation.org.au/lga. Please refer to the ‘2016 Entry Information’ document in particular for details on how to apply and the assessment criteria. The ‘Example Application’ and National Teleconferences (details of dates/times and how to register are on the website) can help you with structuring your application and what information to include.

Email your completed form and three images to your State Coordinator by 5pm Friday 20 May 2016.

APPLICANT DETAILS

Local Government Name [Add text]

State [Add text]

Category ☐ Councils with populations under 5,000☐ Councils with populations 5,000 – 25,000 ☐ Councils with populations greater than 25,000

Contact Name [Add text]

Position [Add text]

Postal Address [Add text]

Phone [Add text]

Email [Add text]

How did you hear about these awards? [Add text]

Has your Council applied in previous years? ☐Yes Year/s: ____________☐No

Have you registered your interest to lodge an application with your Local Government Awards State Coordinator?

☐Yes☐No

Privacy StatementWe respect your privacy. Your personal information is only being collected for the Heart Foundation Local Government Awards and will only be shared with contracted affiliates and service providers. If you want more information about privacy (what we collect, who we share it with and why, or how to access information we hold about you) please see our Privacy Notice at www.heartfoundation.org.au, or contact Teresa Gadaleta at teresa.gadaleta@heartfoundation.org.au, or call (08) 8224 2888. [HFPSBG(1)-140318]

2016 Application Form

COUNCIL PROFILE

Using the table below, please describe the main characteristics of your local government area. While this section is not assessed, the judges will refer to the information presented when reviewing and scoring your application. Throughout your application it is important to demonstrate the link between your council’s strategic plans and policies, the initiatives being implemented, and the demographics/key health issues you have described here (i.e. are they relevant/appropriate for your community).(200 word maximum)

Geographic size of your Local Government Area (square kilometers)

[Add text]

Current population sizeNote: Council population size will be confirmed using the most recent Australian Bureau of Statistics Census data.

[Add text]

Age profile [Add text]

Cultural diversity (including Aboriginal and Torres Strait Islander peoples)

[Add text]

Income, education and employment status of householders

[Add text]

Key health issues [Add text]

APPLICATION SUMMARY

Please provide a summary of your application. This summary may be printed in the Heart Foundation Local Government Awards winner profile booklet and used for case studies and promotional purposes. (250 word maximum)

[Add text]

ABOUT YOUR HEALTHY COMMUNITY

Q1 List your councils’ relevant strategic documents (including plans, policies, positions) Describe how these link to the healthy community elements (listed on pg. 2 ‘2016 Entry

Information’) Describe how these guide your work to improve the health of your communityRefer to ‘2016 Entry Information’, Q1.1 (500 word maximum)

[Add text]

Q2 Provide a summary of two key initiatives that your council is implementing. NOTE: If you are in the ‘Councils with populations under 5,000’ category, provide a summary of one key initiative.

(800 word maximum per initiative)

INITIATIVE ONE

Name of the initiative and a brief description.

[Add text]

When the initiative commenced and was completed (if not ongoing).

[Add text]

Approximate budget.

[Add text]

Who is the target group?

[Add text]

Why was this target group chosen? What is the rationale/identified need for the initiative in this group/community (link to your Council Profile). Refer to ‘2016 Entry Information’, Q2.1.

[Add text]

What strategic documents (outlined in Q1) link with this initiative? Refer to ‘2016 Entry Information’, Q2.2.

[Add text]

What are the main objectives? Which healthy community elements (outlined on pg.2 ‘2016 Entry Information’) do your objectives align with? Refer to ‘2016 Entry Information’, Q2.3.

[Add text]

Provide details on the process used to develop the initiative. Include what processes and tasks were undertaken to engage with, and meet the needs of the community (e.g. community consultations, marketing, establishment of advisory groups etc). Refer to ‘2016 Entry Information’, Q2.4.

[Add text]

Describe community and internal and external stakeholder involvement. How did they contribute to the development and implementation of the initiative? Include funding and/or resource contributions.Refer to ‘2016 Entry Information’, Q2.5.

[Add text]

Were the objectives met? What were the main outcomes and achievements?

[Add text]

How did you measure the outcomes? What evaluation methods were used? Include evidence that there was a positive impact on the target group. Refer to ‘2016 Entry Information’, Q2.6

[Add text]

Does the initiative have long-term sustainability? Can it be maintained/progressed into the future? Describe how (e.g. continuation of the initiative, funding, demand from the target group and ongoing participation, next steps and future goals/plans). Refer to ‘2016 Entry Information’, Q2.7.

[Add text]

INITIATIVE TWO

Name of the initiative and a brief description.

[Add text]

When the initiative commenced and was completed (if not ongoing).

[Add text]

Approximate budget.

[Add text]

Who is the target group?

[Add text]

Why was this target group chosen? What is the rationale/identified need for the initiative in this group/community (link to your Council Profile). Refer to ‘2016 Entry Information’, Q2.1.

[Add text]

What strategic documents (outlined in Q1) link with this initiative? Refer to ‘2016 Entry Information’, Q2.2.

[Add text]

What are the main objectives? Which healthy community elements (outlined on pg.2 ‘2016 Entry Information’) do your objectives align with? Refer to ‘2016 Entry Information’, Q2.3.

[Add text]

Provide details on the process used to develop the initiative. Include what processes and tasks were undertaken to engage with, and meet the needs of the community (e.g. community consultations, marketing, establishment of advisory groups etc). Refer to ‘2016 Entry Information’, Q2.4.

[Add text]

Describe community and internal and external stakeholder involvement. How did they contribute to the development and implementation of the initiative? Include funding and/or resource contributions.Refer to ‘2016 Entry Information’, Q2.5.

[Add text]

Were the objectives met? What were the main outcomes and achievements?

[Add text]

How did you measure the outcomes? What evaluation methods were used? Include evidence that there was a positive impact on the target group. Refer to ‘2016 Entry Information’, Q2.6

[Add text]

Does the initiative have long-term sustainability? Can it be maintained/progressed into the future? Describe how (e.g. continuation of the initiative, funding, demand from the target group and ongoing participation, next steps and future goals/plans). Refer to ‘2016 Entry Information’, Q2.7.

[Add text]

Q3 In addition to the key initiatives described in Q2, describe the range of initiatives your council is implementing and how these demonstrate a ‘whole-of-council’ approach to improving the health of your community. Refer to ‘2016 Entry Information’, Q3.1 (600 word maximum)

[Add text]

APPLICATION CHECKLIST

All boxes must be checked for applications to be accepted

☐Consent for use of information, quotes and photographs provided in your application has been obtained.

☐Three jpeg images are included with your application and, if requested, ten high quality photos (>1 MB) can be supplied.

☐All the questions in the application form have been answered and meet the word limits specified.

☐The Conditions of Entry have been read.

☐None of the initiatives in the application have used funds from Butt Free Australia.