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DCCC Free Services Registration Form
Please fill out the form so we can contact you about these services. 感謝您對華人活動中心活動有興趣，請填寫以下報名表，方便我們聯絡您，謝謝！
webpages: https://www.dallasccc.org/event-info?id=3758, https://www.dallasccc.org/event-info?id=3964
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* Indicates required question
First Name 名
*
Your answer
Last Name 姓
*
Your answer
Gender 性別
*
Female 女
Male 男
Other 其他
Age 年齡
*
Your answer
Email 電子信箱
*
Your answer
Home Zip Code 郵遞區號
*
Your answer
Phone Number 電話
*
Your answer
How do you know about this event? 您如何知道此次活動？（可多項選擇)
Newsletter 中心電子報
Website 中心網站
Facebook 中心臉書
Google Group
Line/WeChat
Newspaper 報紙
Friend 朋友
Other 其他
Whether or not to receive emails from DCCC? 是否願意收到中心相關信息？
Yes 是
No 否
Clear selection
Which program(s) are you interested in? 請問您對哪個項目有興趣？（可多項選擇)
*
Hepatitis C Screening C型肝炎篩檢
FIT (for Colon Cancer Screening) 大腸癌糞便潛血測試（需事先到中心領取樣本收集工具和說明，報名後請等通知再前往領取）
Free Mammograms 免費乳房X光檢查
Free Pap Smear 免費子宮頸抹片檢查
Required
Do you have medical insurance? 請問您是否有醫療保險？
Yes 是
No 否
Clear selection
Are you with limited family income? 是否符合低收入家庭標準？
Yes 是
No 否
Clear selection
Comments 其他問題
Your answer
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