The University of Hong Kong

Henry Chan Inclusive Education Fund 2009-10

Application Form

Please select ONE of the following education grants:

Education Award: Please fill in part A to C, F to H, M and N

Grant to Procure Learning Aids/Services*: Please fill in part A to E, M and N

Grant for Research Project /Activity / Programme / Publication*: Please fill in part A to B and I to N

(A) Particulars for Person-In-Charge

1.  Name in English (Prof./Dr./Mr./Mrs./Miss*): ______

Name in Chinese (if applicable): ______

2.  Date of Birth: ______

3.  Nationality: ______

4.  University / Staff Number*: ______

5.  Job Title (for Staff only): ______

6.  Faculty / Department: ______

7.  Curriculum (for Student only): ______Year of Study: ______

8.  Home Tel. No.: ______Daytime Contact: ______

9.  Email Address: ______

10.  Correspondence Address: ______

______

(B)  Particulars for Group Member(s), if any

If more than one group member, please attach a separate sheet and provide the following personal data of each member.

  1. Name in English (Prof./Dr./Mr./Mrs./Miss*): ______
  2. Name in Chinese (if applicable): ______
  3. University / Staff Number*: ______
  4. Job Title (for Staff only): ______
  5. Faculty / Department: ______
  6. Curriculum (for Student only): ______Year of Study: ______
  7. Daytime Contact: ______
  8. Email Address: ______

* Please delete as appropriate

(C) Particulars of Disability

1.  Type of Disability: ______

2.  Severity of Disability (Please attach the most recent medical report / supporting document if available)

______

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(D) Family Particulars

Household members
Name (Age) / Relation with applicant / Occupation / Monthly income

(E)  Particulars of Learning Aids / Services* Required

(Original quotation sheet(s) for the purchase of learning aids should be attached)

Type of learning aids/ services* / Estimated costs / Describe how this can assist you in your studies

(F)  Academic Achievement (Copies of supporting documents e.g. result slips, transcripts should be attached)

1.  Cumulative GPA: ______

(Remark: For students without GPA, please provide copies of the latest examination result slips for reference.)

2. Scholarships and Awards:

Please give details of any scholarships / awards previously received or currently being granted with information on award date, issuing authority and value of the awards.

Name of Award / Issuing Authority / Value of Award / Award Date

* Please delete as appropriate

(G) Extra-curricular Activities and Social Services

List in chronological order the extra-curricular activities and /or social services you have taken part in the

past three years.

Activity / Service / Position held with details of your role / Period

(H) Please state how you intend to use the fund if your application is successful

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(I)  Project Title: ______

______

______

(J)  Expected Completion Date: ______

(K) Amount of Grant Requested: ______

(L)  Objective(s) of the Funded Project:

(Original project proposal together with the budget breakdown and quotation sheet(s) for the purchase of goods, if any must be attached.)

______

______

______

______

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(M)  Any other information which you consider relevant to this application

______

______

______

______

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(N) Declaration

I confirm that to the best of my knowledge all information contained in this application is accurate.

Signature of Applicant (Person-In-Charge): ______

Name (in full): ______

Date: ______

Remark:

Completed application form together with copies of relevant supporting document(s) should be returned in soft copy to the Secretary, Steering Committees of HKU 81 Inclusion Fund and Henry Chan Inclusive Education Fund via email at by 14 December 2009 (Monday). Please provide details on a separate sheet if deemed necessary.

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