Hong Kong Road Cycling Race - Series 4 (Fei Ngo Shan Road) 全港公路單車賽 - 第四回合 (飛鵝山道)
Health Declaration Form 健康申報表
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Email *
Surname 姓 *
First Name 名 *
Contact Number 聯絡電話 *
Travel History 外遊記錄 *
Travel History 外遊記錄 Areas Travelled Away from Hong Kong 曾前往香港境外的地區
在過去14 天内,閣下或同住人士是否曾經收到衛生署的檢疫令?In the past 14 days, have you or your home-mates received quarantine order issued by the Department of Health? *
在過去14 天内,閣下或同住人士是否曾經收到衛生署的醫學監察要求?In the past 14 days, have you or your home-mates been asked to conduct medical surveillance by the Department of Health? *
有沒有以下病徵(請在適當選項剔(√)) Do you have the symptoms listed below ? *
閣下是否曾經與傳染病患者有緊密接觸?Have you closely contacted with the patient with infectious diseases *
I ("I"refer to the Applicant and Guardian, where applicable, in this declaration) understand that cycling activities are highly hazardous and grave personal injury or death may result therefrom. I declare that I am physically fit, sufficiently trained and well equipped for the races. The Cycling Association of Hong Kong, China Limited (“CAHK”) shall not be liable for any injury or death which I may suffer in the races, due to my own negligence or inadequacy in health and fitness. I agree to abide by the regulations and policies of CAHK. For any violation, CAHK have my consent to terminate any races, claim for compensation and dismiss my right of participating in the races. I hereby expressly declare that I am taking part in the races at my own risk and responsibility. I will abide by the Articles of CAHK, Race Regulations of CAHK , Union Cyclists Internationale(UCI) Race Regulations, SF&OC Anti-Doping Rules and UCI Anti- Doping Rules. I hereby waive all rights, claims and causes of action I have or may have against CAHK, its staff, employees, agents, freelancer, volunteers, independent contractors, sponsors, promoters, supporters and all other contributors from all liabilities for illness, personal injuries, death, loss and economic consequences I may suffer from or incidental to my taking part in the races howsoever caused, including but not limited to negligence and gross negligence. I have read and understand the Privacy Policy of CAHK posted in CAHK's website. Provision of all information is on a voluntary basis, true and correct and complete. CAHK is not obliged to review and shall not be responsible to any consequence arising from the errors or omissions to the information I provided. I agree and accept the use of information, including transfer and disclose of the information, in relation to the races and/or further arrangement. For any change to the information, written notice will be given to CAHK immediately. I hereby grant permission and assign all rights, title and interest to CAHK for utilizing my appearance, images, voice and personal data in connection with the races in all media throughout the world perpetually and agree to waive any right of inspection or approval associated therewith. If there is any inconsistency or conflict between the English and Chinese versions of this Statement, the Chinese version shall prevail.本人(在本聲明中,"本人"包括申請人和監護人(如適用))明白單車活動皆為極高危項目,有可能導致嚴重人身損傷或死亡。 本人聲明本人身體狀況適合及具備足夠訓練、能力及裝備,參與比賽。如本人因個人疏忽或健康及體能上的不足而導致受傷或死亡,本人明白中國香港單車總會有限公司(“總會 ”)將無需為本人在比賽中遭受的任何傷害或死亡負責。 本人明白及願意遵守總會所訂定之一切規則。若有違反,本人同意總會會即時終止有關比賽﹑要求賠償及取消本人比賽資格之權利。 本人鄭重聲明本人是自願參加比賽,並願意自行承擔所有風險及責任。 本人謹遵守總會會章、總會的香港單車 比賽規例、UCI的比賽規例、港協暨奧委會運動禁藥條例及UCI藥物檢查條例。 本人謹此豁免總會及其職員、僱員、代理人、自由工作者、志願工作者、獨立承包人、所有贊助商、推廣人、支持活動之團體及任何有關之團體對於本人參加比賽,包括但不限於疏忽及重大疏忽,所引致之疾病、人身受 傷、死亡、經濟損失之任何法律責任,以及放棄任何有關之權利、索償及追究行動。 本人已閱讀及了解總會上載於網頁上的私隱政策。本人向總會提供之個人資料屬自願性質,資料完整及確實無誤,總會無責任覆核資料,並不須對本人因資料錯誤或遺漏而引起之任何索償或損失負任何責任。本人接 受及同意有關資料用於與此申請及其後相關安排之直接用途,包括資料之轉移及披露。任何資料如有更改,本人會立即提交書面通知總會處理。 本人願意授權總會在毋須本人審查而可以使用本人的肖像、影像、聲線及個人資料作為活動籌辦及推廣之用。 本聲明的英文版本及中文版本如有不符或互相 牴觸,一概以中文版本為準。
I have read and agree to the Personal Information Collection Statement Disclaimer 我已經閱讀並同意 收集資料聲明 *
Contact Information
Organizer : The Cycling Association of Hong Kong, China Limited
Email Address : jacob.y@cycling.org.hk
Tel : 2504 8173
A copy of your responses will be emailed to the address you provided.
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