社会福利署

社会福利署私营残疾人士院舍「自愿登记计划」申请表Social Welfare DepartmentV oluntary Registration SchemeApplication Form1. 院舍名称: ________________________________________________Name of the Home (in Chinese)________________________________________________(in English)2. 地址Address: ___________________________________________________3. 电话Tel. No.: _________________ 传真Fax No.: ____________________4. 电邮地址Email Address: _________________________________________5. 营办人／营办机构* 名称Name of Proprietor／Organization:5.1 _______________________________________________________ (in Chinese)5.2 _______________________________________________________ (in English)6. 香港身份证号码HKIC No.: ____________________7. 地址Address: ___________________________________________________8. 电话Tel. No.: _________________ 传真Fax No.: ____________________9. 电邮地址Email Address: _________________________________________10. 负责人／主管* 姓名Name of Operator／Manager:10.1 ___________________________ (in Chinese)10.2 _________________________ (in English)11. 香港身份证号码HKIC No.: ____________________12. 地址Home Address: ______________________________________________13. 电话Tel. No.: _________________ 传真Fax No.: ____________________14. 电邮地址Email Address: _________________________________________15. 商业登记Business Registration : No. __________________(请呈交副本Submission of photocopies)16. 楼面面积Floor Area ( M2 ): __________________(除平台、户外地方及花园以外的楼宇总面积)(Total area of premises excluding podium, open space & garden area)(请呈交有关最新的图则／楼宇内部间隔图则。

详情请参考附件一。

)(Submission of relevant and up-to-date drawings／layout plans. Please refer toAnnex 1 for details.)17. 租金及差饷Rent & Rates17.1 每月之租金, 如适用Rental ($ p.m.), if applicable: $17.2 每季之差饷, 如适用Rates ($ p.q.), if applicable: $18. 宿位数目Capacity: _________________19. 截至As at ___________ (日期Date)入住人数共No. of residents: ____________(请于附件二填写所有院友资料)(Please fill in the information of residents in Annex 2)20. 每月之住宿收费Fees ($ p.m.): ______________________21. 按金, 如适用Deposit ($), if applicable: _______________22. 其他收费，请注明Other Charges, please specify : _________________________________________________________________________________________ 23. 职员Staffing(请于附件三填写所有职员资料.)(Please enter all particulars in Annex 3 attached.)24. 医疗服务Medical Service24.1 是否有注册西医到诊Is／are visiting doctor(s) available? ______________24.2 到诊次数Frequency of visit: ______________*请将不适用去Delete whichever inappropriate25. 声明Declaration:据本人________________(全名), 香港身份证号码__________________所知，上文所填报资料，均属正确无讹，全属事实，特此声明。

本人已阅读及明白「私营残疾人士院舍自愿登记计划申请须知」的内容，并愿意遵守该文件所述规定。

I, _________________ (Full name), holder of HKIC No. _____________, declarethat to the best of my knowledge, the above information is accurate and true. I havealso gone through and understood the content of the “Notes of Application forV oluntary Registration Scheme for Private Residential Care Homes for Persons withDisabilities” and will comply with the conditions stated therein.营办人／负责人／主管签署：Signature of Proprietor／Operator／Manager: ______________________( )全名Full Name日期Date: _____________________备注：填写申请表时，请先细阅附件四。

Remark: Please go through Annex 4 before filling in this application form.只供社署职员填写Official Use only附件一Annex 1提交私营残疾人士舍图则指引Guidance Notes on Submission of Floor Plans for PRCHD1.应提交两套图则。

申请人应在每张图则上妥为签署〔如以个人名义申请〕或盖上公司／机构的印鉴〔如以公司／机构名义申请〕。

1. 2 sets of floor plans should be submitted. Each plan should be duly signed by the applicant(if the applicant is an individual) or stamped with the company／organization chop (if the applicant is a company or an organization).2.应把私营残疾人士院舍名称〔中英文〕、地址〔中英文〕及提交图则的日期清楚写在每张图则上。

of home ( in Chinese and English), address (in Chinese and English) and the date ofsubmission should be clearly written on each plan.3.每张图则须按1：100 或1：50 的比例来绘制。

至于只显示院舍一小部份的图则，1：20的比例也可接受。

3.Each plan should be drawn to the scale of 1：100 or 1：50. For part plan, 1：20 is alsoacceptable.4.应用红线标示申请自愿登记的范畴。

4.The area of the home to be registered should be demarcated in red on the plan.5.应标明拟设的私营残疾人士院舍处所的总实用楼面面积及总人数〔包括宿位及职员〕〔请参阅《残疾人士院舍实务守则》第六章6.2段〕。

5.The total net floor area and number of persons (including the staff and disabled) of theproposed premises should be indicated. (Please refer to para.6.2 of the Code of Practice for Residential Care Homes for Persons with Disabilities 2002 March).VRS Form 1附件二Annex 2目前所收纳的残疾人士注：1 : 特殊学校 2 : 庇护工场 3 : 辅助就业 4 : 综合职业训练中心5: 综合职业康复服务中心6:日间展能中心7 : 训练及活动中心8 : 家居训练及支援服务9 : 职业治疗10 : 物理治疗11 : 临床心理服务12 : 社区精神健康连网服务13 : 精神科社康护士14 : 社康护士15 : 日间社区康复服务16 : 严重残疾人士日间照顾服务17 : 个人发展计划18 : 新近失明人士支援计划19 : 其他津助训练服务* 请于适当地方加上 号5Rev.12/2007附件三Annex 3# 请提交有关学历证明(文员、司机、㕑务、清洁什工除外)Relevant documentary proof (except clerk, driver, catering and cleaning staff)附件四收集个人资料之前致资料当事人的通知书向社会福利署提供个人资料之前，请先细阅本通知书。