Connect Overseas Service Learning Grant

Connect Overseas Service Learning Grant

侍學行海外服務學習資助計劃

Application Form

Note:

Please return the completed and signed application form IN PERSON, together with copies of supporting documents (if applicable),toHKUST Connect Office at Room 1001, 1/F (via lift no. 4), Academic Building.
The application form must be typed or written clearly and legibly. Check ()appropriateboxes where applicable.
To ensure strict confidentiality of personal data, applications via e-mail/fax will NOT be accepted. Incomplete applications (e.g. failure to provide the necessary supporting documents) or late submissions will NOT be considered.

PART IPersonal Particulars
Name in English: / Name in Chinese:
Surname, first name / (if applicable)
Gender: / M F / Student ID: / Admission Status: / Local Non-local
School: / Year of Study:
Program: / ITSC Email:
Contact No.:
Home / Mobile
Home address:
PART IIFamily Financial Condition

(A)Government Grant & Loan and University Financial Aid:

Academic Year 2017/18 / Academic Year 2016/17
I have applied / will apply for:
Tertiary Student Finance Scheme (Grant/ Loan)
Non-means-tested Loan Scheme (NLSFT)
University Financial Assistance (UFA) / I have applied for:
Tertiary Student Finance Scheme (Grant/ Loan)
Non-means-tested Loan Scheme (NLSFT)
University Financial Assistance (UFA)
Application successful, assistance offered / Application successful, assistance offered
(Grant $ / Loan $ / (Grant $ / Loan $
NLSFT $ / UFA $ / ) / NLSFT $ / UFA $ / )
Result not yet known / Application unsuccessful
Application unsuccessful / Application withdrawn
Application withdrawn
I have not applied any financial assistance in this academic year / I have not applied any financial assistance in this academic year

(B)Family Information Sheet

Please complete Appendix A

(C)Give details about your financial condition in the space below if there have been any significant changes in the financial situation of your family or any special hardship you have encountered.

PART IIService Learning Trip Application

Please indicate which service learning trip(s) organized by HKUST Connect you have applied:

Cambodia Service Learning Trip (6 – 13 June 2018)

Guizhou Service Learning Trip (3 – 11 June 2018)

Jiangxi Service Learning Trip (6 – 11 June 2018)

Nepal Service Learning Trip (1 – 9 Apr 2018, tentative)

PART IIICommunity Service Experience

List and describe briefly the most significant community services you have participated in, using Appendix B. You may be asked to provide documentary proof of the above record.

PART IVCheck List

Check () the below boxes to ensure the following required documents are enclosed with your completed application form before submission.

Family Information Sheet (Appendix A)

Record of Community Service (Appendix B)

PART VApplicant’s Declaration

I understand that the sponsorship may be granted subject to acceptance into and participation in the service learning trip. If I fail to complete the endorsed service learning trip satisfactorily, the sponsorship will be withdrawn.
I understand that references from the administrators of the endorsed HKUST Connect program(s) I previously engaged in will be taken into account during the application process.
I declare that the information provided above is true and correct.I understand that my application will not be considered, and I shall forfeit and refundthe allowance released to me if the information is found to be falsified.

Signature: / Date:

The personal information provided in this application form will be used for eligibility verification, submission to the donor and the University,and compilation of data for statistical purposes.

For office use only

Appendix A

Family Information Sheet

Student Name: ______Student ID:______

Please provide current information of your family and complete Section A-D:

Section A: Home of residence
Please put down the postal address of your family in the space provided and indicate such property is self-owned, on mortgage, or on rental. Check () and delete as appropriate
Self-owned with mortgage Yes No
If yes, monthly mortgage: HK$ / Rental Private Public housing
Monthly rent: HK$
Section B: Applicant, applicant’s parent(s), and/orsibling(s) (please use extra space provided if necessary) (stated in Hong Kong Dollars)
CN / Name / Age / Relationship with Applicant / *Present Occupation /Employment
(state name of post and grade/rank) / Present Monthly Income
(in HKD) / Name of Employer/ Company
OR
School Name / Year of study / In present Job (e.g. date joined Company)
OR
unemployed
(since dd/mm/yy) / Other Income (monthly average in HKD) (e.g. Rental Income of Property/ Business Profit/ Pension/ contributions from others) / Bank Deposit
(in HKD)
(state “Nil” if no deposit owned) / Stocks, Shares and Other Assets
(in HKD)
(state “Nil” if no stock, share or other assets owned) / Whether receiving CSSA from SWD#
NOW
(Yes / No)
1 / Applicant / $ / $ / $ / $ / Y / N
2 / Father / $ / $ / $ / $ / Y / N
3 / Mother / $ / $ / $ / $ / Y / N
4 / $ / $ / $ / $ / Y / N
5 / $ / $ / $ / $ / Y / N
6 / $ / $ / $ / $ / Y / N
7 / $ / $ / $ / $ / Y / N

* If your parents are taxi-drivers, construction workers or decoration workers, you are required to submit their income proof.

# Comprehensive Social Security Assistance from Social Welfare Department of Hong Kong Special Administrative Region Government

Section C: FamilyEstate/Land Property(excluding the self-owned premise of residence indicated in Section A)(stated in Hong Kong Dollars)
Total value of the estate/land property of the applicant’s family / HK$ ______
NO, my family does NOT own any estate/land property excluding the self-owned premise of residence indicated in Section A / How many property units owned? / ______unit(s)
NO, my family does NOT own any estate/land property excluding the self-owned premise of residence indicated in Section A
Section D:APPLICANT’S OTHER FAMILY MEMBERS – Applicant’s siblings living away from the family (including those living in the Mainland or Overseas) and/or any other persons residing with the family but not included in Section B
CN / Name / Age / Married/ Single / Relationship with Applicant / Occupation / Monthly contribution to applicant’s family (in HKD)
8 / $
9 / $
10 / $
11 / $

Appendix B

Record of Community Service

Student Name: ______Student ID:______

List and describe briefly the most significant community services you have participated in. You may be asked to provide documentary proof for this record.

Service Period(month/year) / Program Name / Organizer(s) / Roles / Total Service Hours / Service Location