Inclusive Activity Fund - Reimbursement Request

SEN Service, Wellness and Counselling Centre, Office of Student Affairs

● Please complete this reimbursement form and upload the following within one month after completion of the activity:
1. Attendance list with participants’ names and staff/student numbers (if applicable)
2. activity photos
3. (For internal units) copies of receipts and any associated credit card statements for online purchases
4. (For student groups) electronic receipts and associated credit card statements for online purchases; any hard-copy receipts must be submitted to SENS (3/F, Pommerenke Student Centre, CUHK)

● Enquiries: 3943 5441 / sens@cuhk.edu.hk

Last updated: July 2023

1. Applicant Category *

1. Applicant Category CUHK College/Department/Unit Student Organization/Society/Interest Group Registered/Affiliated with OSA Informal Student Group
2. Name of Responsible Staff/ Principal Coordinator for Student Group (in English) 2. Name of Responsible Staff/ Principal Coordinator for Student Group (in English) * First Last
3. Affiliated College/ Department/ Unit *
3. Student Group Name *
4. Contact Number *
5. Email Address *
Activity Details
6. Activity Name *
7. Date(s) & Time *
8. Venue(s) *
9. Number of People Enrolled *
10. Total Number of Participants *
10a. Number of CUHK Staff Participants (if applicable)
10b. Number of CUHK Student Participants (if applicable)
11. Total Amount of Expenses (HK$) *
12. Total Funding Required from SENS (HK$): *

Should be equivalent to the actual amount of expenses or the funding cap of HK$6,000, if actual expenses exceed HK$6,000
13. Please upload at least 5 activity photos. *

Attach Files
14. Please upload the attendance records with participants' names and student/staff ID (if applicable). *

Attach Files
15. Please submit copies of receipts as one PDF document here.

Attach Files

If there were online purchases, please also submit copies of credit card statements associated with the payments.
15. Are there any electronic receipts?

15. Are there any electronic receipts? Yes No

If electronic receipts are the only proof of payment. please select 'Yes'.

For hard-copy receipts, please send the original receipts to SENS (3/F, Pommerenke Student Centre, CUHK) by internal mail/post/hand.
15a. Please attach the electronic receipts as PDF here.

Attach Files

For purchases settled by credit cards, please also attach the credit card statement displaying the proof of transaction - please hide all other personal information as appropriated.
15b. Sum of Expenses in All Electronic Receipts Uploaded (HK$) *
15c. Sum of Expenses in All Hard-copy Original Receipts to be Submitted to SENS (HK$) *

Input '0' if not applicable
Disbursement Information

(For student organizations/ groups only)
16. Bank Account Holder Name *
17. Bank Name *
18. Bank Account Number *
19. Copy of Bank Card/Statement with the Bank Account Information *

Attach Files
Disclaimer The personal data collected will be used by SEN Service (SENS) and authorised personnel for processing the captioned purposes in accordance with relevant provisions of the Personal Data (Privacy) Ordinance.

Inclusive Activity Fund - Reimbursement Request

Activity Details

Disbursement Information