The Hong KongPolytechnicUniversity

Student Affairs Office

High Flyers’Club

Membership application form (2009/10)

(To be completed by applicant)

A) Personal Particulars

Name / (Eng) / (Chi)
Student I.D. / Age
Category / □Local / □Non-local / Sex
Course / Year of study / A.G.P.A
□Exempted if nominated by SAO
Contact no / (Mobile) / (Home)
Mailing
Address
E-mail / 1) @polyu.edu.hk / Fax
(if any)
2)

B) Language ability (Pls put a tick in the appropriate box)

Fair / Fluent / Proficient
English
Putonhua
Cantonese

C) Give details of co-curricular/ extra-curricular activities participated in the past 3 years (in reverse chronological order)

Period
(From when to when by Month/Year) / Name of Activities / Programmes / Duties/Roles

D) Awards (academic & non-academic)

Year of the award/ prize/ scholarship / Name of the award/ prize/ scholarship / With support document
(pls put a tick  and submit as attachment)
Academic / Non-academic

E) Your talents/ competences (Pls put a tick and specify in the appropriate box)

Category / Brief description / Remarks
(For office
use only)
Sports
(e.g. Basketball, Soccer, Triathlon) / □
Arts & Design
(e.g. Editing, Photography, / □
Social/ Cultural performance
(e.g. MC, Drama, Musical) / □
I.T. & Others
(e.g. Good at using software for website design, video-production) / □

F) Areas for further self-enhancement (Pls put a tick  in the appropriate box)

Attributes / Programme /activity you are interested to join
(e.g. training, competitions, conferences, service trips etc) / Remarks
(For office
use only)
Leadership / □AIA Foundation Young Leaders Development Programme
□Others: ______
Global Outlook / □HK Model United Nations Conference
□Global Citizenship Programme
□International Youth Exchange Programme
□Other: ______
Entrepreneurship / □HK Social Enterprise Challenge
□GSC PolyU Pre-Challenge
□HSBC Young Entrepreneur Awards
□Young Entrepreneurs Development Council E-Challenge
Others: ______
Social responsibility / □“I Generation” Youth Integrity Programme by ICAC
□Community Service Learning Project Award (CSLP)
□Others: ______
Problem-solving / □AIA The Outstanding Financial Planning Awards for Hong Kong Undergraduates
□The Challenge Cup Competition
□Others: ______
Others
(Pls specify) / [Presentation/ Public Speaking]
□The AIA-Quest for the Champion Communicator
□Inter-University Speech Contest “Metro Lions Cup”
[Teamwork/ Organization]
□ Providence Foundation Outward Bound Training
□Suggested programme/ activity:
______
G) Application check list
Please mark the checklist below as relates to your role in the application process. All documents are required to hand in by photocopies only.
 / PolyU academic report (Pls submit the most recent one; or exempted if nominated by SAO)
 / Academic certificates obtained
 / Certificates on awards/ prizes obtained ( ______pieces)

H) Declaration

I, / (name of applicant), declare that this
application has my consent and that the information given by me in this form is complete and true to the best of my knowledge. I authorize the Student Affairs Office (SAO) to handle and use the personal data/information provided by me, and any supplementary information as required by SAO for activities relating to the handling and assessment of this application. I understand the above personal data/information will be kept, subject to full erasure within one year upon my graduation from PolyU.

______

Date Signature of applicant