Early Detection of Cognitive Impairment Project

The Awareness, Prevention and

Early Detection of Cognitive Impairment Project

Phase V (“APEC V”)

Application Form

Note:

Applications must be submitted by 5pm on 29September 2017. Late application will not be considered

Each NGO can submit one application only but can operate the project in more than one district and through more than one centre/service unit. Each district can have more than one centre/service unit operating the project

Please attach (i)documentary proof on the exemption from tax under Section 88 of the Inland Revenue Ordinance (Cap.112); (ii) audited accounts of the previous year; and (iii) organization chart and list of the board of directors

The application form, along with all the aforementioned required supporting documents, shall be submitted

Deletion of any item or amendment of the prescribed format is not acceptable.

The applicant NGO must agree and pledge to fulfill all the responsibilities and deliverables as set out in the Invitation for Proposals

The project must commence in December 2017 and be completed by 28 February2019

1. Particulars of the Applicant NGO

1. Summary of Application

1. Target no. of participating elders (maximum 200): ______

1. Target no. of young-old volunteers (minimum 1 volunteer to 5 elders ratio): ______

1. District(s) to operate the project :

1. Amount to be requested from the Simon K Y Lee Elderly Fund:

(pledged no. of participating elders) x $5,000 = $______

1. Relevant Experience

1. Applicant NGO’s records and experience in providing services related to dementia or cognitive impairment, including the content, beneficiaries and impact etc.

1. Recruitment, Engagement and Retention of Participating Elders

1. Networks of applicant NGO and their relevance in helping the latter to reach elders with MCI in the community.

1. Strategy, mechanism and approach to provide screening tests for elders in the community and to recruit those with MCI to undergo the one-year structured physical and cognitive activities

1. Possible factors affecting the participating elders’attendance/ compliance and retention in the project; corresponding measures to overcome the difficulties.

1. Measures and mechanism to keep track of and monitor the participating elders’activity attendance and compliance.

1. Provision of Physical and Cognitive Activity Sessions

1. Preliminary plans on the types of physical and cognitive activities to be provided for the participating elders, in what format these activities will be provided and the value-added measures (if any) to make them attractive to the participating elders. Indicate whether i) new classes will be organized specifically for APEC participating elders, or ii) APEC participants will be admitted to existing activity groups.

1. Young-old Volunteer Programme

1. Strategy and approach to recruit young-olds aged 50 and up to be volunteers of the project; measures to boost up morale and encourage active participation and continuous commitment.

1. Training, programmes/activities and support to be provided for the young-old volunteers, including the objective, content/themeand targeted output.

1. Sustainability Plan

1. Plan and strategy to sustain the APEC Model once the grant ends, e.g. continue to deliver services according to the APEC Model, or further recruit MCI elders and provide them with related services etc.

1. Staff Arrangement

1. Number, qualification and experience of staff to be recruited or deployed for the project and the structure of staff supervision

1. Budget

1. Budget for the Project, including the breakdown of proposed expenditure.

[Note: Payment is on a lump-sum basis. NGOs need not return to the Elderly Fund any unspent balance. The Elderly Fund will not be responsible for any and all cost overrun. ]

1. Declaration of Applicant NGO

[Note: this partmust be signed and completed by the Agency Head or Board Chairperson of applicant NGO]

I certify that all the information given in this application is true and accurate. I understand that any inaccurate information will make the applicationinvalid; the Simon K Y Lee Elderly Fund will withhold any funding allocation and payment made must be refunded.

I consent that the information provided in this application form will be used by the Simon K Y Lee Elderly Fund for processing the application and for related purposes.

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