Part Ageneral Information

Application Form for the Elder Academy

Part AGeneral Information

Name of the Elder Academy: ______

1.Participating School (PS)

Name: ______

Address: ______

Telephone No.: ______Fax No.: ______

Email address: ______

Brief description of the school:

______
(For example, the history, mission and work of the school. Annual report of the school, if any, may also be submitted.)

Name of the Principal: ______

Telephone no.: ______Fax no.: ______

Email address: ______

Name of Contact person: ______Post title: ______

Telephone no.:______Fax no.:______

Email address: ______

2.Participating Non-governmental organisation (NGO)

Name: ______

Address: ______

Telephone no.: ______Fax no.: ______

Email address: ______

Name of person-in-charge: ______Post title: ______

Telephone no.: ______Fax no.: ______

Email address: ______

Name of contact person: ______Post title: ______

Telephone no.: ______Fax no.: ______

Email address: ______

3.Contact person of the Elder Academy:

Name: ______Post title: ______

Telephone no.: ______Fax no.: ______

Email address: ______

Part BProgramme Outline of the Elder Academy

1.Programme and course content of the Elder Academy:

______

2.Estimated number of participants in the Elder Academy: ______

3.Estimated number of students participating in the Academy and the mode of programme (e.g. students teaching elders computer courses):

______

4.Is the PS’s vision in line with the development of the Elder Academy?
Yes □ No □
If the answer is yes, please give a brief description:

______

5.Will the Elderly Academy offer at least two courses within six months upon approval of the application?
Yes □ Course title Note:______No □
______

Note : One of the courses must be selected from the compulsory health courses listed in Annex 2 of the Application Guidelines; whereas the other one must be an academic course (e.g. language, computer, history, literature, etc.).

6.Is the PS ready to let the Elder Academy use the school facilities (such as computers, classrooms and assembly halls) for holding activities?
Yes □ No □
Details:

______

7.Has the PS ever co-organised any intergenerational harmony programmes with elderly centres or NGOs?
Yes □ No □
If the answer is yes, please specify the types of programmes:

______

8.How many hours per week is the PS prepared to operate the Elder Academy (not less than 6 hours as suggested)?

______

9.What are the plans to facilitate the operation of the Elder Academy and to achieve self-financing in the long run?

______

10.What are the plans to facilitate the setting up of the management committee of the Elder Academy?

______

Remarks : Declaration on Collection of Personal Data (Privacy)

1. Information provided in this form will be used exclusively by the Committee on Elder Academy Development Foundation under the Elderly Commission for consideration of applications and distribution of service newsletters.

2. The person who fills in this form may at any time contact our staff for access to or amendment of his/her personal data [Data Protection-F002].

3. Please contact theCommittee’s Secretariat for any enquiries about the provision of personal data.

Part C Declaration

1. The programme mentioned in this form is not for profit-making, or for promoting politics, religions or business for any individual or organisation;

2. We have read and understood the guidelines for the operation of the Elderly Academy. We agree to comply with the rules of the programme.

Signature of Supervisor of the PS: ______
(on behalf of the sponsoring body)
Name of the Supervisor: ______

Signature of Principal of the PS: ______
Name of the Principal: ______

Person-in-charge of the NGO: ______
Name of the person-in-charge: ______Date: ______

Please return the duly completed form to the Committee on Elder Academy Development Foundation Secretariat.
Correspondence Address: 10/F, West Wing, Central Government Offices, 2 Tim Mei Avenue, Tamar, Hong Kong
Telephone No.: 3655 5861 / 2810 3007 Fax No.: 2523 1973