Hong Kong University of Science and Technology



Enrichment Program for Gifted Learners (Winter 2016)

Course Enrolment Form (Primary Section)

Application deadline has been extended to 24 Oct 2016

Please complete the form in BLOCK letters and return it along with crossed cheque(s) and relevant documents (see Checklist on P.4) to the following address.

|Address: The Center for the Development of the Gifted and Talented, |

|The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, HK |

|(*Please state - Application for EPGL on the envelope.) |

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A. Course Enrolment

|Application Details: |

| |Course Details |Please refer to: |

| |Application Period |20 Sept 2016 (Tue) – 12 Oct 2016 (Wed). ***Application deadline extended to 24 Oct 2016 (Mon). |

| |Application Procedure |Please complete the Course Enrolment Form and return it along with a crossed cheque (payable to “The Hong Kong University of |

| | |Science and Technology”. Please write down the student name, school name, course code and parent’s/guardian’s contact number |

| | |on the back of the cheque.) and all documents (including the most recent School Academic Report, copies of document certifying|

| | |applicant’s academic competence (if any), School Recommendation Form (optional, download from website) etc.) to the address |

| | |below on or before the application deadline: |

| | | |

| | | |

| | | |

| | | |

| | | |

| |Application Result |Application results will be released via email on 02 Nov 2016 (Wed). |

| |Important Notes |Course fees are not refundable unless the enrolment is not successful. Please beware and avoid time clash between any other |

| | |courses and activities. After results announcement, no course fees will be refunded, transferred or retained under any |

| | |circumstances. |

| | |Make-up lesson will not be provided unless classes are cancelled due to adverse weather condition. CDGT and HKUST will have |

| | |full discretion on fixing the date, time and venue of the make-up lessons. If any student is unable to attend no |

| | |refund/compensation in any form nor further make-up lesson will be arranged. |

| | |Please ensure your application bear sufficient postage before posting. |

| |Enquiries |Email: cdgt@ust.hk Tel: 2358 5084 Fax: 2358 2201 |

| |

|Course sign up (Please fill in the information below and or put a ( in the boxes where appropriate) |

| |Course Name: | M106 Blended Learning in Mathematics |

| |Course Fees: |HK$1,200 |

| |Cheque No.: |__________________ |

| |Name of Bank: |_________________________________________________________ |

| |How did you learn about EPGL Program? |

| | |

| |   Friends |

| |   Facebook |

| |   Website |

| |   School |

| | |

| |   HKAGE |

| |   UST Staff Newsletter |

| |   Others (Please Specify)：_________________________ |

| | |

B. Personal Particulars

(Please make sure that the information given are correct as all the important notices will be sent according to the information provided.)

|Surname (English) |Given Name (English) |Surname (Chinese) |Given Name (Chinese) |Gender |

|      |      |      |      |      |

|Date of Birth (dd-mm-yyyy) |Residential Phone No. |Student Mobile Phone No. |

|      |      |      |

|Student E-mail Address ( Please provide an active address as important notices will be sent by email) |

|      |

|Correspondence Address |

|      |

|Name of School in Chinese (2016/17 school year) |

|      |

|Name of School in English (2016/17 school year) | |

|      |

|Level attending (2016/17 school year) | | |

|      |Example: P3 (Y4/G3) ; P4 (Y5/G4); P5 (Y6/G5); P6 (Y7/G6) |

|Have you ever skipped a grade at school? |

| Yes. (Year：       From         To        study level) |

| |

|No. |

|Have you ever enrolled in any CDGT courses? |

| |

| |

|Yes |

| |

|CDGT Student ID (if any): |

|      |

| |

| |

|Year of latest course attending: |

|      |

| |

| |

| |

|Course(s) you attended: |

| |

| |

| |

|No |

C. Parent’s / Guardian’s Information

|Surname (English) |Given Name (English) |Surname (Chinese) |Given Name (Chinese) |

|      |      |      |      |

|Relationship |Emergency Contact No. |E-mail Address |

|      |      |      |

D. Applicants with Special Learning Needs

|Do you need special arrangement in learning and/or taking course tests? |

| |

|Yes. (Please specify below. You may consider providing medical certificate(s) or educational psychological report(s) as supporting documents): |

| |

|____________________________________________________________________________________________ |

| |

| |

|No. |

E. Academic Background and Additional Information:

*In the table below, provide information of no more than 3 examinations/competitions/events relevant to the subject area of the course(s) you are applying and provide copies of certificates/proofs (if any):

| |Date (MM/YY) |Name of Examination / Competition / Event |Issuing Organization |Grade / Award obtained |

| |From |To | | | |

|1 |      |      |      |      |      |

|2 |      |      |      |      |      |

|3 |      |      |      |      |      |

F. Important Notes:

|Please make sure that the Course Enrolment Form has been duly completed and all documents (including the most recent School Academic Report, copies of document|

|certifying applicant’s academic competence, School Recommendation Form (optional, download from website) etc.) have been enclosed for application. Incomplete |

|application forms will not be processed. Late applications will not be considered. |

|Personal data provided are used by the Center for the Development of the Gifted and Talented (CDGT) only for purposes of enrolment, student administration, |

|research and educational purposes. All submitted documents will not be returned. |

|Only crossed cheques are accepted. Please do not pay by post-dated cheques, postal orders or cash. |

|Applicants should meet the admission requirements of each course. |

|All fees paid are non-refundable, non-transferable, and non-retainable. |

|CDGT reserves the right to make any alterations to the course as deemed necessary. CDGT also reserves the right to cancel a course due to insufficient |

|enrolment or other unforeseen circumstances, in which case full course fees will be refunded. |

|Certificates will be issued to students who have completed the course successfully. For details, please refer to individual course descriptions. |

|Under no circumstances will the University be liable for any accident, losses, and injuries or any other expenses incurred resulting from the attendance at, or|

|participation in any of the activities offered by CDGT. |

|Declaration |

| |

|Personal data provided in this form will be used for course application and research purposes, for both the Center and other related departments within HKUST|

|and other organizations and agencies authorized where necessary. Under normal circumstances, personal data of unsuccessful candidates will be destroyed |

|within 24 months upon rejection of application. |

|The Center will use your personal data (in particular your name, contact, and background information) in order to communicate with you regarding various |

|activities organized by the Center and the University, including the promotion of events, seminars, programs, training, fund raising, support for special |

|initiatives, etc. Your consent is required for this communication practice. |

|******************************* |

|The applicant and his/her parent(s)/guardian(s) agree the Center and the University to use my personal data for communicating with me regarding the various |

|activities organized by the Center and the University, including the promotion of events, seminars, programs, training, fund raising, support for special |

|initiatives, etc. |

|The applicant and his/her parent(s)/guardian(s) agree for CDGT and HKUST to use the workshop/class photos for promotion. |

|*If you wish to update your personal data, or cease receiving our communications, please email us at cdgt@ust.hk. |

|I declare that the information provided is true and correct. The applicant and I have read and understood the Regulations set out by the CDGT, and hereby |

|sign to indicate my unreserved agreement with all its contents. |

| |

|Course fees are not refundable, transferable, nor retainable after results announcement on 02 Nov 2016 unless the enrolment is not successful. Make-up lesson|

|will not be provided. |

| | |

|Signature of Applicant’s Parents/Guardians: |Date: |

| | | | |      | |

| | |

Checklist: Documents Required (Please check the box(es) to indicate the documents submitted.)

| Course Enrolment Form |

| Copies of most recent School Academic Report (Required) |

|If any: Copies of any other document certifying applicant’s academic competence (SAT, World Class Tests or other academic competence ) |

| Crossed Cheque (HK$1,200) |

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The Center for the Development of the Gifted and Talented

The Hong Kong University of Science and Technology

Clear Water Bay, Kowloon, Hong Kong

(Remarks: Please sᰀ[pic]ᰤ[pic]ᰦ[pic]ᰪ[pic]ᰬ[pic]᱖[pic]ᱚ[pic]ᱜ[pic]ᱰ[pic]ᲂ[pic]ᲆ[pic]ᲊ[pic]Ჰ[pic]Ჲ[pic]Ჶ[pic]Ჸ[pic]Ჺ[pic]ᴮ[pic]᷆[pic]ᷚ[pic]᷾[pic]Ḁ[pic] [pic] [pic] [pic]‒[pic]•[pic]‣[pic]‥[pic]…[pic][pic]
[pic]훱떹麩麒蚒鹸麒땴ctate Applying EPGL on the envelope.)

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