CE1_09 Application Form-1

CE1/09

CE1/09

A

B

APPLICATION FOR THE REGISTRATION OF A COMMUNITY ENGAGEMENT PROJECT

PERSONAL PARTICULARS 1.

Name of Applicant:

2.

Department:

3.

Faculty:

4.

Staff number:

PARTICULARS OF PROJECT Title of project 1.

2.

Community to be served: Names of fellow project members (if applicable):

3.

4.

C

(a)

of the Department of

(b)

of the Department of

(c)

of the Department of

(d)

External Community Liaison Officer (see D3 below)

Approximate expected duration of the project:

SIGNATURES 1.

Applicant

Date:

Head: Department of 2. Name:

Signature:

Date:

Signature:

Date:

Representative: Faculty of … 3. Name:

© 2008 • Community Engagement Working Group • UNIZULU.

CE1/09

D

CONCISE DESCRIPTION OF THE PROJECT

1.

Title of project _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

2.

Brief description of community with whom the project will engage _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

3.

Community leader or contact person within the community Name: ________________________________________________________________________ Designation/Position: ____________________________________________________________ Contact no: ____________________________________________________________________ e-mail: ________________________________________________________________________

4.

What intervention is planned? Over what time frame? In what phases? Intervention: ___________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Overall time frame: ______________________________________________________________ Phase 1: ______________________________________________________________________ Phase 2: ______________________________________________________________________ Phase 3: ______________________________________________________________________

5.

What outcomes are expected? What community capacity will develop? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

6.

How will the success of the project be measured? How will the project be monitored and evaluated? Measure/s of success: ___________________________________________________________ _____________________________________________________________________________ Monitoring and evaluation: ________________________________________________________

© 2008 • Community Engagement Working Group • UNIZULU.

CE1/09

7.

Specific activities and names of staff members responsible for them Name: ____________________________________________________________________ ____ Activity:______________________________________________________________________ Name: ________________________________________________________________________ Activity: _______________________________________________________________________ Name: ________________________________________________________________________ Activity: _______________________________________________________________________

8.

Role of students and nature of learning that will take place _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

9.

Modules or postgraduate courses for which participating students are enrolled Code: _____________ Title: ______________________________________________________ Code: _____________ Title: ______________________________________________________ Code: _____________ Title: ______________________________________________________

10.

Research outputs that may emanate from the project _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

E

APPLICATION GUIDELINES 1. Only projects within the University’s community will be considered (North of the Tugela 2. 3. 4. 5. 6. 7. 8. 9.

River) Funding will be capped at R 20 000 per annum per project. Furniture (fixtures and fittings) will not be considered for funding. Projects should have a defined lifespan (maximum 3 years). Projects should aim at building community capacity. Projects should aim at building relationships. Projects should stand as models of good practice. Projects should aim at contributing to problem-driven, practically-based research, action and knowledge creation. Ideally, projects should also be registered with the Central Research Committee

© 2008 • Community Engagement Working Group • UNIZULU.

CE1/09

F

BUDGET AND MOTIVATIONS 1. Accommodation and subsistence Place

Type of Accommodation (e.g. hotel)

No. of Days

Rate

R

c

Sub-total Motivation: __________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Travel costs Type of Transport*

Destination Indicate from where to where

Distance

Rate

R

C

Sub-total 2 * If by car, indicate the cm Motivation: ________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 3. Fieldworkers/student assistants Name of Assistant*

Highest Qualification

Remuneration Rate Days

Sub-total *If a number of assistants will be used, only the number need be given.

© 2008 • Community Engagement Working Group • UNIZULU.

R

c

CE1/09

Motivation: __________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 4. Technical services and consumable goods (Provide a detailed breakdown) Type of services / goods 1. 2. 3. Sub-total

R

c

Motivation: __________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 5. Other expenses (specify) Type of additional expenses

R

c

Sub-total Motivation: _________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ GRAND TOTAL

R _______________

6. Amount applied for now (current year):

R _______________

7. Amount of financial assistance received from other sources: Source 1 ___________________________________________ R _______________ Source 2 ___________________________________________ R _______________

© 2008 • Community Engagement Working Group • UNIZULU.