Stoke City Football ClubCommunity Fund

Stoke City Football Club,

Stoke City Community Fund,

bet365 Stadium,

Stanley Matthews Way,

Stoke on Trent,

Staffordshire, ST4 4EG

Application Form Contact details, About your Group, About your Project, Community Referee, Contact Details: First Name: Surname: Position in the group: Contact address: Postcode: Group Address (if different): Postcode: How can we contact you? Daytime number: Evening number: (Optional) phone: Your email address: Confirm email: Group email address: Confirm email: Should we need to contact you, please indicate your preferred method of being contacted? Telephone/ Email

Group Name Are you a registered Charity Y/N If yes, please provide your charity number: What does your group do? When was your group set up? Month Year Please indicate how many of the following you have Volunteers: Full time staff: Part time staff: How many people will be actively involved in making this project work? Are you able to provide us with a copy of your most recent accounts? Y/N If NO (what is the reason for this)

About Your Project Please describe the project that you would use the funding for: Please tell us who will benefit from your project:

Is your project ongoing: Y/N Is your project a one off event: Y/N Other Where do the majority of people live who will benefit from this project? Area Post Code Please provide us with a breakdown of the costs of your project. Listing all expenditure. Item Total Cost of Item 1 £ 2 £ 3 £ 4 £ 5 £ 6 £ 7 £ 8 £ 9 £ 10 £ If the total cost of your project is more than the amount that you are asking us for. How will you secure the rest of the money required to deliver your project.

If we chose your project to receive funding what name would you want to appear on the cheque? Community Benefit Which community benefits will your project achieve? (Please highlight the most appropriate boxes and then give details on each) Access to Services Active citizenship Arts & Culture Community Community Safety Education Equality and deliver Environmental Health Sports

What will be the community benefits with your project? Will this project offer any form of sustainability? What experience do you have or does the group have of running similar projects? If you were successful in receiving a grant how would you let others know that Stoke City have helped? Would you allow a small plaque to be placed in a suitable place to recognise Stoke City’s support Y/ N

Would you allow media coverage of your project? Y/ N Community Referee Your Community Referee must be somebody who is aware of the project but they will not benefit from the project. This person must not be related to the applicant. Please provide contact details of your Community Referee. First Name Surname Address 1 Address 2 Address 4 Postcode Daytime number Evening number How did you hear of the Stoke City Community Fund? if you require this document in word format please contact 01782 592273.

For any further questions contact us:

By Post: Stoke City Football Club, Stoke City Community Fund, bet365 Stadium, Stanley Matthews Way, Stoke on Trent, Staffordshire. ST4 4EG

By email: communityfund@stokecityfc.com