DSOBA Sports Facility- Health Declaration Form
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Email *
Date of using sports facility 使用場地日期 *
MM
/
DD
/
YYYY
Facilities Required 使用場地 *
Name of Member 會員姓名 / 使用者姓名 *
Full name on HKID
Class year
For teaching staff, please fill in "1900", For family of members, please fill in "1901".
Contact Number 聯絡電話 *
Symptoms (病徵) *
No -沒有
Yes- 有
Fever 發燒
Chills & Rigor 發冷
Cough 咳嗽
Diarrhea 肚瀉
Shortness of Breath / Difficulty in Breathing 呼吸急促/ 呼吸困難
Other Symptoms 其他病徵
Please Specify if tick Yes in Other Symptoms above 如在上列選擇其他病徵請列明
Close contact with Covid-19 Patients (e.g. home, work or other place) or Covid-19 Patient yourself *
為新冠肺炎患者或其緊密接觸者 (例如同住，工作及其他地方）
If you have any symptoms or ticked any "Yes" above, please refrain from joining the sports activity on the date, thanks
如出現病癥，或於上述問題選擇＂是＂，請避免出席是日體育活動，謝謝。
Travel History within the past 14 days 過去14天的外遊記錄
Place & Period 地方及日期 (Leave it blank if not applicable沒有請留空)
State the destination(s) if you will travel outside Hong Kong for any reason in the coming 30 days 在未來30天內因任何理由須離開香港，請列明所到地方
(Leave it blank if not applicable沒有請留空)
HKID FIRST 5 digit/character *
HKID first 5 digit and character, eg Z123456(7) input Z1234
Notice
Please note that by submitting this form, you acknowledge that you have given true, accurate and complete information concerning your health which is imperative to making available and ensuring the continuous use of the sports facilities within the school campus. In the event that DSOBA considers that the information you have provided is untrue or inaccurate or incomplete, DSOBA shall exercise its discretion as regards whether any follow-up is required.
A copy of your responses will be emailed to the address you provided.
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