HLTH1010/602B

(July 2017)

Activities Module
Community or Voluntary Work
Application for Endorsement
by Department/Office of HKUST

Please send the completed application form together with the event proposal and the required documents to the HLTH1010 Course Office (Room 1013, via Lift 3 or take the stairs next to Tsang Shiu Tim Art Hall) at least 20 working days before the commencement of the event.

Incomplete application will NOT be processed.

* Please delete as appropriate. # Please mark “X” in the appropriate □.

Name of Staff Applicant / : / *Prof./ Dr./ Mr./ Miss/ Ms.
*Dept./Office/Center / : / Post / :
Email / : / Tel. No. / :
Service Project Name / :
Nature of Service # / : / □ Elderly □ Youth □ Sports □ Disabled □ Others (please specify)______
Date(s) & Time / :
Actual Service Hours / : / service hours per attempt x attempts = hours
Venue / :
No. of Participants / : / (Estimated no. of HLTH1010 Students: )
Event Fee # / : / □ No □ Yes, HK$__ __ per participant (Please attach the budget proposal for fee-charging event)
Will participants receive other course credits for this service? # □ No □ Yes (Application will NOT be considered)
Will participants receive remuneration or honorarium for the service? # □ No □ Yes (Application will NOT be considered)
Name of Partner Organization / :
Contact Person / : / *Prof./ Dr./ Mr./ Miss/ Ms.
Post / : / Tel. No. / : / Email:
Address / :
Confirmation by partner organization attached: # / □ No □ Yes
Intended Learning Outcomes (ILOs):
Please indicate the HLTH1010 Course ILOs and related details that the participants are expected to achieve through participation in this community or voluntary work: (Please use separate sheet if the space below is not enough)
Students can identify the following techniques to enhance their personal growth and wellness development:
a.
b.
c.
Event Proposal listing the following information attached: # □ Yes □ No (Application will NOT be considered)
-  Content
-  Rundown
-  Work Schedule / -  Safety precautions (if appropriate)
-  Budget plan (for fee-charging event) / -  Attendance taking arrangement
-  Ways to ensure active participation
-  Ways to assess ILOs
Proposed HLTH1010 Course hours for endorsement: service hours per attempt x attempts = hours / service hours per attempt x attempts = hours

As the Person-in-charge of this application, I agree to monitor the delivery of the proposed activities as set out in this application, and to submit an event report with (a) activity photos, (b) summary of the activity, and (c) the prescribed attendance record to the HLTH1010 Course Office within 7 working days upon completion of the event.

I understand that late submission will NOT be accepted.

Signature of Staff Applicant: / Date:

For HLTH1010 Course Office Use

Activity: COMVOLUN / Event Code: / ______
Endorsed Recognized Hours:
Max. _ __ hour(s): _ __ hour(s)per attempt x _ __ attempt(s) on __ / from to
Endorsed by: / Date:
Endorsement Notice Sent to Applicant by Email on / by