For office use only
Received on
Connect Overseas Service Learning Grant
侍學行海外服務學習資助計劃
Application Form
Note:
1. Please return the completed and signed application form IN PERSON, together with copies of supporting
documents (if applicable), to HKUST Connect Office at Room 1001, 1/F (via lift no. 4), Academic Building.
2. The application form must be typed or written clearly and legibly. Check () appropriate boxes where
applicable.
3. 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 I
Personal Particulars
Name in English:
Name in Chinese:
Surname, first name
Gender:
M
F
(if applicable)
Student ID:
Admission Status:
School:
Year of Study:
Program:
ITSC Email:
Local
Non-local
Contact No.:
Home
Mobile
Home address:
PART II
Family Financial Condition
(A) Government Grant & Loan and University Financial Aid:
Academic Year 2016/17
Academic Year 2015/16
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 (NLS)
University Financial Assistance (UFA)
Application successful, assistance offered
(Grant $
Loan $
NLSFT $
UFA $
Result not yet known
Application unsuccessful
Application withdrawn
I have not applied any financial assistance in this
academic year
Application successful, assistance offered
(Grant $
Loan $
NLSFT $
UFA $
Application unsuccessful
Application withdrawn
I have not applied any financial assistance in this
academic year
)
(B) Family Information Sheet
Please complete Appendix A
161119
1
)
(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 III
Service Learning Trip Application
Please indicate which service learning trip(s) organized by HKUST Connect you have applied:
Singapore Service Leaders Exchange Tour (15 – 19 January 2017)
PART IV
Community 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 V
Check 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)
Access to Personal Data Consent Form (Appendix C)
PART VI
Applicant’s Declaration
1. 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.
2. 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.
3. 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 refund the 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
2
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/or sibling(s) (please use extra space provided if necessary) (stated in Hong Kong Dollars)
CN
Name
Age
Relationship
with Applicant
*Present
Occupation
/Employment
Name of
Employer/
Company
OR
School Name /
Year of study
Present
Monthly
Income
(in HKD)
(state name of post
and grade/rank)
In present Job
(e.g. date joined
Company)
OR
unemployed
(since dd/mm/yy)
Other Income
(monthly average in
HKD) (e.g. Rental
Stocks,
Shares and
Other Assets
(in HKD)
Bank Deposit
(in HKD)
(state “Nil” if
no deposit
owned)
Income of Property/
Business Profit/
Pension/ contributions
from others)
(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
3
Section C: Family Estate/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$ ___________________
How many property units
owned?
NO, my family does NOT own any
estate/land property excluding the self-owned
premise of residence indicated in Section A
_____________unit(s)
NO, my family does NOT own any
estate/land property excluding the selfowned 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
Monthly contribution to applicant’s
family (in HKD)
Occupation
8
$
9
$
10
$
11
$
4
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)
5
Roles
Total
Service
Hours
Service
Location
Appendix C
6