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1、附附 錄錄 AppendixQEFMH (2010) Page 1 of 9 伊利沙伯女皇弱智人士基金撥款申請表伊利沙伯女皇弱智人士基金撥款申請表 Application for a Grant from Queen Elizabeth Foundation for the Mentally Handicapped (QEFMH)擬議計劃擬議計劃 Proposed project(中文) (in Chinese)(必需填寫 required)計劃名稱 Project name (最多廿五字) (in 25 words maximum)(英文) (in English)(必需填寫 require
2、d)申請的計劃申請的計劃 Scheme applied (please tick the appropriate ONE) (必需填寫 required)每張申請表只可提交每張申請表只可提交一個一個計劃計劃 Please use separate form for EACH scheme 智障人士高齡化服務支援計劃智障人士高齡化服務支援計劃 (申請資助額為申請資助額為港幣港幣$20,000 至至$100,000)請答第請答第(i)項項 Please go to item (i) Scheme to Support Aged Persons with Intellectual Disabilit
3、y (Amount of grant applied should be from HK$20,000 to HK$100,000) 獨立生活設備支援計劃獨立生活設備支援計劃 (申請資助額為申請資助額為港幣港幣$20,000 至至$50,000) 請跳答第請跳答第(ii)項項 Please go to item (ii) Scheme to Support Persons with Intellectual Disability for Independent Living Facilities (Amount of grant applied should be from HK$20,000
4、 to HK$50,000) 一般資助計劃一般資助計劃 (申請資助額為申請資助額為港幣港幣$30,000 以上以上) 請跳答第請跳答第(iii)項項 Please go to item (iii)General Support Scheme (Amount of grant applied should be above HK$30,000)計劃計劃性質性質 Nature of proposed project (i)智障人士高齡化服務支援計劃的性質(請選出最適切的一項) Nature of Scheme to Support Aged Persons with Intellectual Di
5、sability(please tick the most appropriate one) : 購置器材、設施 purchase of equipment/facilities ( 康復 rehabilitation 訓練 training 資訊科技、電腦 IT, computer 康樂 recreation) 小型工程 minor capital works 服務及訓練 service and training 公眾教育 public education 康樂 leisure and recreationQEFMH (2010) Page 2 of 9 伊利沙伯女皇弱智人士基金撥款申請表伊
6、利沙伯女皇弱智人士基金撥款申請表 Application for a Grant from Queen Elizabeth Foundation for the Mentally Handicapped (QEFMH)(ii) 獨立生活設備支援計劃的性質(請選出最適切的一項) Nature of Scheme to Support Persons with Intellectual Disability for Independent Living Facilities (please tick the most appropriate one) : 購置器材、設施 purchase of e
7、quipment/facilities ( 康復 rehabilitation 訓練 training 資訊科技、電腦 IT, computer 康樂 recreation)(iii) 一般資助計劃的性質(請選出最適切的一項) nature of General Support Scheme (please tick the most appropriate one) : 購置器材、設施 purchase of equipment/facilities ( 康復 rehabilitation 訓練 training 資訊科技、電腦 IT, computer 康樂 recreation) 小型工
8、程 minor capital works 服務及訓練 service and training 公眾教育 public education 康樂 leisure and recreation計劃詳情計劃詳情 Description of proposed project (下述每項最多五十字) (in 50 words maximum for each of the following items)(iv) 目的 objective (必需填寫 required)(v)舉辦理由(必須闡明如何透過建議的計劃達至上述計劃的目的) justifications (must elaborate ho
9、w the objective of the project outlined above can be achieved through the proposed project) (必需填寫 required)(vi)地點 location(vii)計劃推行時間#: 約 月/年* (*請刪去不適用的) (必需填寫 required)Project period #: about month / year* (*delete if inappropriate) ( 由 From 至 to )請於附件一詳細列出計劃各項活動及日程 Please list detailed implementat
10、ion schedule of all project activities at Annex I# 開始日期不應早於 2010 年 10 月 Project should not commence before October 2010(viii) 計劃的服務對象及預計受惠人數 (必需填寫 required) Target group(s) and approximate number of beneficiaries of the project：智障人士智障人士(Persons with Intellectual Disability) 輕度輕度(Mild)中度中度(Moderate)嚴
11、重嚴重(Severe)-兒童(children) -青少年 (teenagers) QEFMH (2010) Page 3 of 9 伊利沙伯女皇弱智人士基金撥款申請表伊利沙伯女皇弱智人士基金撥款申請表 Application for a Grant from Queen Elizabeth Foundation for the Mentally Handicapped (QEFMH)-成年(Adults) 智障人士家長智障人士家長 (Parents of persons with intellectual disability) 受薪照顧者受薪照顧者,例如特殊教師、職業治療師例如特殊教師、職
12、業治療師 (Paid Carers of persons with intellectual disability, e.g. special school teachers, Occupational Therapists, etc.) _義工義工 (Volunteers) 大大眾眾 (the general public) (ix)這項計劃的開支總額(請於附件二詳列各項預算開支數額) Total cost of the project (with detailed and itemized estimates of costs at Annex II)港幣 HK$ (x)是否已經或將會向政
13、府部門和其他機構申請資助這項計劃的開支(請列明部門/機構名稱和申請數額)： Whether assistance has been/will be sought from Government departments or other organisations for the project (if yes, please provide details on the Government departments/organisations and the amount sought)(xi)這項計劃是否會涉及長期的經常開支及相關數額(如屬試驗計劃，則請說明資助期完結後是否仍有這類開支) I
14、mplications on long term recurrent expenditure and amount involved (including implications of a pilot project after the sponsorship)(xii)日後應付上述第(xi)項長期經常開支的安排Future funding arrangement for the long term recurrent expenditure in item (xi) above:由申請機構調配內部資源應付 To be covered by redeployment of internal
15、resources向政府部門或其他機構申請資助(請列明有關資料) Seek assistance from Government departments or other organizations (please provide relevant details)政府部門 / 有關機構的名稱 :Name of the government departments / relevant organizations:預計數額 (amount sought):HK$其他 (請說明) Others (please specify)QEFMH (2010) Page 4 of 9 伊利沙伯女皇弱智人士基金撥款申請表伊利沙伯女皇弱智人士基金撥款申請表 Application for a Grant from Queen Elizabeth Foundation for the Mentally Handicapped (QEFMH)(xiii) 申請機構是否在香港成立的自助組織 ? Is your organization a self-help organisation
