Term of Service I, IV, VI and H

Date of receipt: _______________________

0715 Revised H7TOS I, VI & H and Fixed-Term with Band G, H, I & J

THE UNIVERSITY OF HONG KONG

INSTITUTE OF HUMAN PERFORMANCEApplication for the Use of University Sports FacilitiesPlease read the notes overleaf and then fill in the details as below:

Personal Details

Name of University Appointee (Mr/Ms): _____________________________________________________________________ (Exactly as it appears on Staff Card) HKID/Passport No: ___________________________________ Staff number: ______________________________________Department/Unit: _____________________________________ Position held: _____________________________________(as given in Letter of Appointment)

Mobile Telephone No: _________________________________ Retirement or Contract End-date: _____________________ Telephone No.: _______________________________________ Email: __________________________________________Family Membership (if applicable)Name (same as the HKID Card/Passport)NA/RE*Date of BirthAgeFAC** No.For Official Use Only

SpouseNA/RE*

ChildNA/RE*

ChildNA/RE*

ChildNA/RE*

*Delete whichever is inappropriate (NA: New Application; RE: Renewal)

**FAC: Facility Access Card

Please put ( in appropriate boxes:Section I - Status

New Application

Renewal (if applicable for principal card)Section II - Total number of Applicants (See overleaf for types and fill in number)( Applicant without Staff Card or FACTotal number: ____________ x HK$35@ = _______________( Staff cardholder/FAC holder

Total number: _______________________________________DeclarationI have read the conditions overleaf and confirm my acceptance of them. I hereby apply for the University sports membership and authorize The University of Hong Kong to deduct the membership fees as agreed by the Committee of Management of Institute of Human Performance (IHP) and the fee of $35 for the first issuance of EACH FAC from my salary and then to charge the membership fee annually up to my retirement or contract end-date as stated above, whichever is earlier, unless this arrangement is cancelled by me in writing to the Director of IHP and by disabling my staff card (and that of my family FAC(s) if applicable) to access the sports facilities. I also hereby affirm that I / my family members am / are in good physical condition to partake in physical activities and/or exercise. My/Our participation is purely voluntary and in no way mandated by The University of Hong Kong. I/We also understand that I/we should monitor my/our own condition throughout exercise/physical activities. I/we should stop the activity or exercising anytime if I/we have any discomfort or even without any particular reason. In no event shall The University of Hong Kong, its officers, employees, or agents be held liable for any injury, death, or property loss which I/we may suffer during the activities if caused by either my/our own negligence, inadequacies in health and fitness or by accident.Date: ___________________________________________Signature: _____________________________________

For Official Use

Remark: ______________________________________________________________________________________________________________

Eligibility

Staff on TOS I, VI & H and Fixed-Term with Band G, H, I & J with their family members are eligible to use University sports facilities, provided they pay the fees prescribed by the University and comply with IHPs rules and regulations. Membership Types Principal member university appointee

Spouse

Child (aged 18 or below) Senior Child (aged 19-24) each senior child will be charged a separate feeApplication Procedures for New Application and Renewal

For both new application and membership renewal, applicants should return this application form, duly completed and signed, to Flora Ho Sports Centre of IHP (111-113 Pokfulam Road, Pokfulam, Hong Kong). As the processing of an application normally takes 7 working days of the General Office of IHP, applicants please come to our General Office (address as above) during its opening hours to collect the membership 7 working days after the application submission. For renewal, applicants should bring along their expired cards at the time of the sport membership collection. Please note that IHP will not issue any notification to applicant individually in regard to membership collection and application submitted by fax will not be acceptedSports Membership Collection1. For Applicants without Staff Card or Facility Access Card (FAC)If applicants do not have a Staff Card or FAC, please come in person to take photo or bring a passport size colour photo(s) taken within the past 6 months to IHPs General Office during its opening office hours. On the back of the photo(s), please put down the family members name and his/her HKID/Passport No./relationship as appropriate.

2. For Applicants with either Staff Card or Facility Access Card (FAC)If applicants have a Staff Card or FAC, please bring your card to IHP for encoding. For enquiry concerning membership application, please call 2817 3657 or 2817 4046.

Fees Membership year starts in every November Membership for less than 12 months will be charged on monthly pro-rata basis

Scale of charges (subject to review): (A) Annual Membership Fees

Principal only$450

Principal & family (excluding Senior Children)$690

Every Senior Child aged 19-24$670

(B) Other Fees

The first issuance of each FAC$35

Replacement fee for each FAC$100

All fees paid are non-refundable

Payment

The membership fees deducted from salary will be made at the time of application and then every November thereafter. If you wish to stop the payment deduction, you are required to cancel your membership (please see below). Cancellation

To cancel the membership, members must write to Director before 15 October and present their Staff Card and all family FAC(s) (if applicable) for deactivation afterwards. Otherwise, the annual membership fee deduction will continue automatically until your membership expires.

Admission

Staff Card/FAC(s) must be produced for each entry to any University sports facility and each use / booking of facilities. After their expiry date, the membership cards will become invalid. On withdrawal of membership or termination of employment, staff card and all family FAC(s) issued for all users should be presented in person or on behalf of your family members for the deactivation of membership.Use of Fitness Room Facilities

Applicants are advised to visit this webpage: http://www.ihp.hku.hk (Sport ( Sports Facilities ( Fitness Centres) for details on the regulations / instructions on using the fitness room facilities.

IHP RESERVES THE RIGHT TO ALTER THE CONDITIONS OF MEMBERSHIP AT ANY TIME.

(Jul 2015) v1