Apply - Tobacco Control NZ

Activation name(Required)

Applicant name(Required)

Enter the key contact name for this activation.

First Last

Organisation or group name(Required)

Email(Required)

Phone(Required)

Date of activation(Required)

If your activation is run over a number of days please tell us your start date and all the dates you intend to deliver the Kaupapa.

Time of activation(Required)

Please indicate the start and end times of your event.

Location of the activation(Required)

Street Address Address Line 2 City Region

Activation summary(Required)

Describe the activities and intentions of your kaupapa

What is the smokefree message for your kaupapa?(Required)

How will you deliver on these messages?(Required)

Have you as an individual or a group been the recipient of a community activation grant before?(Required)

Yes

No

As a second time grant recipient it is a requirement that your event intends to raise quit attempts among your community. Please share how you plan to achieve this.(Required)

How will you track and report the number of quit attempts raised as a result of your activation?(Required)

Budget worksheet

Please outline how you plan to allocate your grant funding. Detail each item and it’s cost. (i.e. Kai for volunteers - $500)

Use as many or as few of the cost item lines as required.

Item 1

Cost

Item 2

Cost

Item 3

Cost

Item 4

Cost

Item 5

Cost

Item 6

Cost

Item 7

Cost

Item 8

Cost

Item 9

Cost

Item 10

Cost

Item 11

Cost

Item 12

Cost

Total

Declaration

Upload any supporting documentation

Documents could include proposal, poster designs etc.

Drop files here or

Accepted file types: jpg, png, pdf, zip, Max. file size: 150 MB.

How did you hear about the Smokefree Community Activation Grant?(Required)

Word of Mouth

Stop smoking service

Other

CAPTCHA

Application form

Smokefree Community Activation Grant

Smokefree grants

Budget worksheet

Declaration

Email

Phone