Grant application form - Course v.2018

Introduction

The ESC will provide funding to support a regional or local educational course related to the aims of the ESC.

The Internal Scientific Committee (ISC) retains the right to refuse an application if it feels the course content is not within the aims and objectives of the Society.

Application

Please use this application form. Note sections with a maximum word count. Forms will be returned if the word count is exceeded. Please complete all sections.
This grant is not given for personal training.
If granted, the course MUST be completed within 24 months
A mentor will be allocated to each course. They are there to offer advice if required and will oversee progress.

Funding

UP to a maximum of 5,000 euro per course can be requested. Usually all of the funding is allocated at the start, but the ISC has the right to arrange part funding if it feels that is more appropriate. A final report together with an evaluation MUST be sent to ISC within 6 months of completion of the course. The ESC may not be in a position to fully fund all applications; you must indicate whether / how part funding may impact your course.
A detailed budget must be included in the application form. Costs can include: planning meeting expenses; production of programme and handouts; evaluation and impact assessment costs; advertising; hire of a hall or room; audio visual equipment. Receipts may be requested for monies spent. Grant money cannot be used for congress registration.
A short CV of the applicant (or the principal investigator) should be integrated into this application. maximum 250 words

Who can apply?

Applicants must be paid up ESC European members with their membership paid within a European country. A European applicant is allowed to submit a grant for a course that will take place outside Europe provided a full explanation of why it should be funded is included. You must remain a paid-up ESC member until the course has taken place and your grant has been signed off by the ISC.

Deadline

Applications MUST be received at ESC Central office by 31st December 2018.

A. Details of applicant requesting the funding

Name of applicant *

Job title *

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number

E-mail *

example@example.com

A short CV of the applicant (or the principal investigator) should be integrated into this application. (Maximum 250 words)

Submission date of this form *

Day Month Year Date Picker Icon

B. Proposed course or meeting

Is the person responsible for the project different to the person named in box A *

Yes No

Name of person

Job title

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number

E-mail

example@example.com

C. Background of the course – narrative summary

Title of the course / meeting *

Sector in the area of contraception, sexual and reproductive health *

Comprehensive description of the course. Is this a ‘stand-alone’ course or part of a larger series of lectures / courses? Include a provisional programme. (Max 200 words) *

0/200

When would it start / finish? (Max 20 words) *

0/20

Where will it take place – country / town, establishment? (Max 20 words) *

0/20

3 learning objectives *

Who will be the audience? (Max 20 words) *

0/20

What outcomes will be measured? Ideally an impact assessment will be undertaken. List. (Max 50 words) *

0/50

Attach a planned evaluation form to be used by the participants to rate the speakers and course content. *

Attach the proforma you plan to use to evaluate the course from the organisers’ point of view. *

Do you foresee any reasons why this course or meeting may not happen? (Max 20 words) *

0/20

D. Financial related information

How much are you requesting from ESC?

Are there other partners or organisations supporting this same course? *

Yes No

If YES - name the other partners who will support this course

0/20

How much money is required for the course in total?

Have you already obtained any funding? *

Yes No

Are you still awaiting a response towards this course? Give details in the table below. *

Yes No

Details of your proposed budget

Add extra lines to the table if required
Costs can include: planning meeting expenses; production of programme and handouts; evaluation and impact assessment costs; advertising; hire of a hall or room; audio visual equipment. Receipts may be requested for monies spent. Grant money cannot be used for congress registration.
List each Item required for this course
For each budgetary item, enter either the amount requested from the ESC or if there is also funding from another partner, list the amount & name of partner.

Budget *

Total amount requested from ESC

Total amount requested from partner(s)

Add any additional information here

The ESC may not be in a position to fully fund all applications; you must indicate whether / how part funding may impact your course. (Max 100 words) *

0/100

Who will oversee the budget and keep accounts? Provide name, title, contact number and email address *

Note: The ESC retains the right to be refunded any unspent money from the grant.

E. Previous funding from the ESC

If you or your department has received funding from ESC for a project or course before, please give details of the date of funding, contact person and title of project or course.

F. Follow up

I/We, as responsible agents for this course/meeting, agree to the following 10 points: *

	yes
I/We agree that all monies will be spent appropriately
I/We agree to provide receipts if requested.
I/We agree to work with the nominated Mentor
I/We agree to advise you at the earliest time if this course/meeting is delayed or cancelled
I/We agree to provide a report, including an evaluation to the ESC within 6 months of the end of the course/meeting
I/We agree to present the ESC with a detailed budget at the end of the course/meeting.
I/We agree that if we need to make any significant changes to the funding of the course after it has been awarded, I/we will advise the nominated mentor
I/We agree that any unspent money will be returned to the ESC
I/We agree to acknowledge the ESC as a donor in any publications and oral communications resulting from this course /meeting.
I/We agree to remain fully paid up ESC member(s) until the final grant report is submitted

Full Name

First Name Last Name

Date

Day Month Year Date Picker Icon

Questions? ESC Central Office: info@escrh.eu / Tel. 0032 2 582 08 52