2019年 Y Not 遊學團
參加者資料及健康申報表 Participant Particulars and Health Declaration Form
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活動及參加者個人資料 Programme and Personal information
參加者姓名 (中文) Name of participant  (Chinese) *
必須與報名時相同
參加者姓名 (英文) Name of participant  (English) *
必須與報名時相同
年齡 Age *
電郵地址 email *
聯絡電話 Tel. No. *
通訊地址 Address *
已報名參與活動 Programme Enrolled *
Required
參加者是否對某種食物或藥會產生敏感反應 ? Is participant known to be allergic any medicine or food? *
參加者現在是否定期接受藥物冶療 ? Is participant under any medication or treatment? *
參加者是否患有以下疾病? Has participant been diagnosed with the following disorders? *
Required
放學安排 After -School Dismissal Arrangement
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其他補充資料 Other information you consider necessary
緊急聯絡人資料 Emergency Contact
緊急聯絡人1 姓名 Name *
緊急聯絡人1與申請人關係 Relationship *
緊急聯絡人1 聯絡電話 Contact No. *
緊急聯絡人2 姓名 Name *
緊急聯絡人2與申請人關係 Relationship *
緊急聯絡人2 聯絡電話 Contact No. *
家長會否出席小朋友成果分享會?
家長會否出席小朋友成果分享會 ?                                  日期 : 8月23日時間 : 17:00-18:30地點 : 基督教尖沙咀潮人生命堂 (九龍尖沙咀寶勒巷25號) *
參加港青活動約定 Agreement
1. 本會將為各工作坊/課程安排攝影師拍攝及錄影小朋友活動情況,相片和影片將被用作活動記錄及宣傳推廣。家長如欲分享小朋友的喜悅,可於活動完結1個月後到社會服務部網頁 www.ymcahk.org.hk/sole 瀏覽相片。若不欲於工作坊/活動被拍攝或將有關資料作上述用途,本會歡迎家長直接向職員反映,本會樂意為 閣下作出相應安排。
2. 參加者和家長已閱讀惡劣天氣政策。
3. 在選擇參加是項活動,參加者和家長了解及自願接受當中可能涉及個人受傷或損失的風險*。
4. 參加者同意採取適當行為和方法確保安全及避免自身和他人受傷。 參加者必須嚴格遵守港青提供的安全條例,規則及建議。
5. 參加者和家長明白及同意不會向香港基督教青年會及其工作人員追究因參加活動而引起的個人或財物損失、受傷或傷害責任。 *損傷範圍可由較輕微的肌肉、關節及韌帶扭傷,瘀傷,裂傷至嚴重受傷如骨折、腦震盪等,甚至引致傷殘或死亡。
1. The YMCA of HK has the right to take photo of or video-record the class activity for the purpose of publicity and record keeping. The photos would also be uploaded to photo album for participants to retrieve at www.ymcahk.org.hk/sole one month after the programme finished. Parents of participants who do not wish their children to be captured by photo or to be shown in any other means, please kindly notify staff in advance. The YMCA of HK will then make proper arrangement.
2. The participant and parents has read the “Bad Weather Policy” for bad weather conditions.
3. The participant and parents are aware of and agrees to undertake possible risks of loss or injury or damage associated with the activities.
4. The participant agrees to take measures to minimize possible loss or injury or damage to the self or others. The participant agrees to observe and abide by the safety rules, regulations and advice of YMCA of Hong Kong.
5. The participant and parents understands and agrees to surrender the rights of legal and financial claims upon the loss, injury or damage associated with the activities.
      *Possible injury includes muscle ache, sprain, bone fracture, brain shock, associated disabilities and death.
本人同意港青使用以下個人資料作為通訊、活動推廣與邀請及收集意見之用途。I agree to give permission to the YMCA of HK to use my privacy information for contact, programme promotion and invitation, and programme evaluation purposes. *
茲證明以上資料屬實並盡本人所知填寫,並已閱讀及明白「參加港青活動約定」的內容。I hereby declare the accuracy of the above information and have read and agreed to the contents in the agreement. *
Required
家長姓名 *
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