Positive Memory Bank - Berry Street

Appendix 7: Assessment form
Funding Category: Up to $500 $500-$1,000 Reference #:
GG Mtg date:
How did the applicant respond to the questions?
Writing Drawings Photographs
Mixture (Describe)
Other (Describe)
Positive Memory Bank
Application Assessment Form
Did they include further information about the activity or opportunity they wish to
participate in?
Yes
No
On a scale of 1-10 (1 – not at all, 10 – Very much so/Definitely) how much do you feel this
opportunity/application:
Criteria Scale Score
Promotes fun – opportunities to play, have adventures,
be a child etc.
Provides ‘Normal’ experiences – opportunities to do
things that other kids do, things that connect the
applicant to their peers and community outside the
welfare system.
Enables a sense of achievement – Things that enable the
applicant to feel like they have something to offer, skills
that people value, the ability to succeed.
Connect children and young people to their family –
opportunities that facilitate and support connection to
family.
Provide resources – equipment and financial resources
that enable them to access recreation and personal
development opportunities such as musical instruments
or the money to pay for music lessons.
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
How satisfied are you that:
If this application is successful the child or young person
could get the support that they need to access this
opportunity? (e.g. Travel support, a worker to go with
them, special clothing or anything else?)
1 2 3 4 5 6 7 8 9 10
Is there anything the PMB should do to ensure they get this support?
Yes
No
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