(Réservé aux organisateurs) Dossier n° 2017/
(Réservé aux organisateurs) Titre résumé: CONFIDENTIEL – DIFFUSION INTERDITE
APPLICATION FORM
You have developed an innovative product or project
helping to combat disability
You wish to submit an application for the
ISPRM/SOFMER INNOVATION CONTEST
PREAMBLE
You certify that the data submitted in this document are the result of your reflection and are not the property of a third party not mentioned as a partner of the project.
You acknowledge that the information transmitted will be reviewed by the contest organisers and is subject to confidentiality. This information will not be transmitted or disseminated to third parties without your consent and that no commercial use will be made of the data.
PROCEDURE
1. Send the application form with the required attachments before the 30th April, 2018 deadline
2. Applications are to be sent by e-mail to with the subject «Application for the innovation contest ISPRM 2018»
3. You will be sent confirmation of the admissibility of your application
4. The Jury will review and select the winners in June 2018, after which you will be informed of the results by the end of June 2018
5. Selected applicants will be invited to exhibit their project at a reduced rate in a dedicated area during ISPRM 2018
6. The results of the contest will be announced during the closing ceremony of the ISPRM World Congress in Paris, on 12th July, 2018.
PROJECT TITLE
Short title (<50 characters):
1. Actors in the project
1.1 Who is the main interlocutor?1
Name, given name of the project initiator 2:
Address:
Phone: Mobile:
Mail:
Occupation:
Leading organisation 3:
Name:
Kind of organisation (company, lab, association…):
Head count:
Address, phone number, mail and website of the support organisation:
Other initiator(s) of the project:
NAME, given name and role in the project4:
1 If there are several project initiators, a representative of the group must be chosen.
2 attach a CV
3 attach a file presenting the company/lab/association…
4 attach a CV for each person involved
1.2 Partners
Is the project driven by only one organisation or in a partnership
In case of partnership, provide for each partner:
NAME of the organisation 5:
Main role:
NAME, given name of the person responsible of the project for each organisation involved:
Address:
Phone: Mobile:
Mail:
Occupation:
5 Attach a file presenting the company/lab/association…
2. The project
2.1 Summary (max. 500 words)
Name of the project:
Objectives of the project:
Rationale (scientific/economic/social):
Current state of development:
Developmentperspective: achieved phases and provisional timetable
Project cost – actual and future:
2.2 Project rationale: initial context, local opportunities, history, progress up to this date (max. 1 page A4)
2.3 Detailed description of the project (max. 4 pages A4)
Clearly state if it is a product or a service;
Describe: 1 - the development and of deployment status; 2 - the innovative nature; 3 - the reliability and the feasibility; 4 - the trials conducted or in progress; 5 - the market analysis; 6 - the marketing perspectives; 7 - the economic valorisation solutions
Attach any file that you think useful.
3. Additional information
Does the project include a design dimension? YES NO
If so, explain why:
Does the project include a sustainable development dimension? YES NO
If so explain why:
Does the project concern human services? YES NO
If so, explain why:
Does the project concern social participation? YES NO
If so, explain why:
Does the project include a development assistance dimension? YES NO
If so, explain why:
4. What are the intended developments of your project?
4.1 Provide a timetable of the future phases of your project?
4.2 What kind of impact do you expect your project to have? (answer every question)
· on disabled persons?
· on the caregivers? (relatives or close persons) (psychologic, ergonomic, relational conditions, etc...) ?
· on the medical staff?
· on the health care system?
· on the social support?
· on some financial aspects?
5. What would you need for the development of your project?
5.1 Budget (max. 1 page A4)
Please present the project budget, and any additional needs to complete your project
Provide the total cost of the project(with some justification)
How much money do you need to request?
Describe in detail the use of your funds.
Timetable of the use of your funds
(specify the resources available and to be found)
Additional details:
5.2 Do you need expert opinion and/or additional partners to complete your project? (max. 1 page A4)
Is so what type?Expert opinion/ partner in technical, scientific, clinic, experimental, economic or commercial areas
What do you expect from this additional expertise?
What would be the modality of this partnership?
How important would be this expertise/partnership would be for your project?
Additional details:
For this project,
Are public aids requested? (If so, from which public organisation?)
Are public aids obtained? (if so, specify the origin and the amount)
Are bank loans requested or obtained? (if so, which bank(s) and which amount?)
Are prizes already won for this project? (if so, which prize)
6. Additional materials:
· You are required to provide the CV and files presenting the company/lab/association
· Add any file you think useful (figures, photos, videos, website links, patents)
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