Prevention of and Treatment for Substance Abuse Act, 2008 (Act No. 70 of 2008)

Regulations

Regulations for Prevention of and Treatment for Substance Abuse, 2013

Annexures

Annexure F : Forms

Form 2 : Application for registration of community-based services

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FORM 2

APPLICATION FOR REGISTRATION OF COMMUNITY-BASED SERVICES

[Regulation 15(1)(a)]

Application by a natural person

Name of applicant: ________________________________________________________________

Surname of applicant: _____________________________________________________________

Identitiy Number of applicant: ______________________________________________________

Application by a person representing a juristic person

I _________________________________________________________________________(full names and identity number) in my capacity as ____________________________________________of _________________________________________________(full name of organization) being duly authorized to act on behalf of _________________________________________________(name or organization) hereby apply for registration of community-based services.

Section A : Basic details of the Service Provider

1.	Registration number of non-profit organisation or company or trust (where applicable)

__________________________________________________________________________

2.	Other registration details (specify) :

__________________________________________________________________________

Has your registration ever been suspected or cancelled? YES/NO

If yes, please provide details:

__________________________________________________________________________

3.	Address details

(a)	Physical and postal address of Administration Office

__________________________________________________________________________

(b)	Physical addresses and telephone numbers of service locations (identify facility)

(i)	___________________________________________________________________

_________________________________________________postal code ________

(ii)	___________________________________________________________________

_________________________________________________postal code ________

(iii)

___________________________________________________________________

_________________________________________________postal code _______

(If there are more service locations please attach a list)

4.	Financial details

(a)	Do you have a bank account? YES/NO

If yes, provide following details

(i)

Bank:

___________________________________________________________________

(ii)	Account name:

___________________________________________________________________

(iii)

Type Account:

___________________________________________________________________

(iv)	Account No:

___________________________________________________________________

(v)	Branch Code:

___________________________________________________________________

4.2	Do you have an auditor? YES/NO

If yes, provide details:

(a)

Name:

__________________________________________________________________________

(b)

Address:

__________________________________________________________________________

(c)	Telephone number: ________________________________________________________

(d)	Attach a copy of your Audited Financial Statements for the past six months (where applicable)

4.3	If you do not have Audited Financial Statements please give the reasons thereof.

__________________________________________________________________________

5.	Governance Details

(a)	Constitution: (Attach a certified copy)

(b)	Details of Governing Body:

List of members of organization (names and identity numbers) [For organisations only]

Details of family interests or relationships pertaining to the organisation and staff:

__________________________________________________________________________

(c)	Do/will you hold General Members Meetings? YES/NO

If yes, attach a copy of the minutes of the last meeting

6.	Beneficiaries

How many persons benefit from the services provided?

__________________________________________________________________________

Declaration

I declare that the above information is true and correct. I understand that any misrepresentation or omission of pertinent information may be considered as sufficient grounds for withdrawal of registration.

Signature _______________________ Place ________________________ Date __________

Full Name:

_________________________________________________________________________________

Capacity:

_________________________________________________________________________________

Copy of ID to be attached

Section B : Community-based services

1.	Description of Community-based care and support services

(a)	Date when the services was first established:

(b)	What services are rendered (please tick) (Attach copy of your services plan)

Awareness raising

Substance abuse educational programmes

Transport

Life skills programme

Early Intervention

Referrals

Treatment

Aftercare + re-integration

Family support services

Marriage enrichment services

Statutory services

Recreation

Income Generation

Socialisation

Culture and Spiritual

Home visits

Advice

Group Support

Education and Training

Counselling (social work)

Other, Please specify

__________________________________________________________________________

(c)	On how many days/per week are the services made available?

__________________________________________________________________________

(d)	During which hours of the day are the services rendered?

__________________________________________________________________________

(e)	Does the service operate over weekends and public holidays?

__________________________________________________________________________

2.	Beneficiaries

Please give a breakdown of persons who benefit from the services on a weekly basis

(a) Total Number of persons:

__________________________________________________________________________

(b)	Total number of persons receiving

(i)	prevention services

___________________________________________________________________

(ii)	early intervention services

___________________________________________________________________

(iii)

treatment services

___________________________________________________________________

(iv)	aftercare and reintegration

___________________________________________________________________

3.	Funding of the Services

(a)	Do you receive a grant/subsidy from the Department of Social Development? YES/NO

If yes, what amount do you receive on a monthly basis?

R _______________________________________________

(b)	Do you receive a grant from the local authority? YES/NO

If yes, what amount do you receive per month or per annum?

R _______________________________________________

(c)	Have you applied for funding from the Department of Social Development which was turned down?

YES/NO

If yes give details:

__________________________________________________________________________

(d)	Do beneficiaries pay for the services? YES/NO

If yes what do beneficiaries pay for the services per month/per day/per hour

R ___________per individual?

If no, please give your reasons:

__________________________________________________________________________

5.	Human Resources

(a)	Do you have paid staff members? YES/NO

(b)	Do you have volunteers? YES/NO

If yes—

(i)	how many? _________________________________________________________

(ii)	do you pay transport costs of volunteers? YES/NO

(c)	Give breakdown of employed staff and volunteers:

POSITION	NO	TASKS

(d)	If you do not use paid staff members or volunteers do you use partnership workers, provided by other organizations?

YES/NO

6.	Service Locations

Provide a list of places and areas where services are rendered.

AREA	PLACE
(i)
(ii)
(iii)
(iv)
(v)

If you render services at more locations please attach a list.

Provide sketch plans of the above facilities

7.	Facilities at main service location (please tick)

Hall

Offices

Kitchen

Store Room

Dining Room

Clinic

Library

Bathrooms/Showers

Toilets

Wash Basins

Other (specify)

__________________________________________________________________________

If you do not have the above facilities at your disposal, how do you render the services? Give details:

__________________________________________________________________________

8.	Basic amenities and equipment to render services at main service location. Please tick below:

Kettle or urns

Stove

Fire

Fridge

Water supply

Power supply

Catering utensils

Plates, cups, etc

Tables and chairs

Recreation equipment

Primary Health Care equipment

Assistive devices (wheel chairs, tripods, commodes, walking sticks

Other, provide list:

__________________________________________________________________________

Please attach a list of the equipment used in the facility

9.	Business Plan

Do you render your services according to a business plan? YES/NO

If yes, please attach your business plan to section B

If no, please indicate the reasons below:

An outreach service from residential care facilities

Other, please specify:

__________________________________________________________________________

If your services are linked to other services, please give details:

__________________________________________________________________________

Prevention of and Treatment for Substance Abuse Act, 2008 (Act No. 70 of 2008)

Regulations

Regulations for Prevention of and Treatment for Substance Abuse, 2013

Annexures

Annexure F : Forms

Form 2 : Application for registration of community-based services

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