Your name Please select the grant you will be a panel member for: - Select -Volunteer Expenses FundLittle Pot of Heath Wellbeing FundLittle Pot of Health Innovation Fund Please select the grant round you will be a panel member for - Select -Round 1Round 2Round 3Round 4Round 5Round 6Round 7Round 8Round 9 Declaration of interest Declaration of interest 1 Organisation Name of individual at the organisation (if applicable) Nature of the interest Is the conflict of interest regarding you or a family member My conflict of interest A family member 2 Organisation Name of individual at the organisation (if applicable) Nature of the interest Is the conflict of interest regarding you or a family member My conflict of interest A family member 3 Organisation Name of individual at the organisation (if applicable) Nature of the interest Is the conflict of interest regarding you or a family member My conflict of interest A family member 4 Organisation Name of individual at the organisation (if applicable) Nature of the interest Is the conflict of interest regarding you or a family member My conflict of interest A family member No interests No conflict of interest to declare Confirmation I confirm that I have no interests to declare Date