樂暢親子共學空間實名制聯絡表單(鮪魚老師)Le Second Floor Kids Studio Health Declaration Real Name system

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防疫新生活運動實名制登記表

享受生活促進經濟,一起響應「防疫新生活運動」
符合下列防疫及安全措施的業者,民眾均可以放心前往消費:
1.保持社交距離,室內1.5公尺、室外1公尺,座位。
2.落實個人衛生防護,如戴口罩、測量體溫、入口及場所內提供洗手用具及設備。
3.建立實名制,並確實執行人流管制及環境清潔消毒。
Enjoy Life and promote Economy with"Epidemic New Life Movement"

Citizens can feel safe to shop and dine at any shops and restaurants meeting the following epidemic control requirements :
1.Social distancing:1.5m indoor and 1m outdoor.
2.Personal hygiene and protection:Wear masks,measure body temperature,and provide washing/cleaning agents
for hands at entrances or in the venues.
3.Real name system:Resister customer names and implement customer traffic control and environment cleaning
and disinfection.

配合空間管理機制,進入空間期間,請全程配戴口罩,手部消毒及測量體溫,若額溫≧37.5度者,將被禁入樂暢親子共學空間.
In accordance with the space management, please always wear a mask when entering our studio, disinfect your hands and measure body temperature. If your body temperature is greater than or equal to 37.5 degrees, we will ask you to leave our studio.

姓名Name: *

孩童姓名 Child Name 1:

孩童姓名 Child Name 2:

孩童姓名 Child Name 3:

聯絡手機 Tel: *

電子郵件信箱Email: *

健康狀況聲明 Health Status Statement *

您與您的家人過去30天內是否出境旅遊? Have you or your family traveled abroad in the past 30 days?Travel history of you and your family member within 30 days.

否 NO

是 YES

填表日前14天內是否有呼吸道感染症狀?(如:發燒,咳嗽,呼吸急促,肺炎等)? Are there any symptoms of respiratory tract infection (such as: fever, cough, shortness of breath, pneumonia, etc.) within 14 days before the filing date?Are you experiencing any of the following symptoms? *

提醒您，若有任何身體不適症狀，請在家休息。Notice: if you have any symptoms of physical discomfort, please rest at home. Please stay home if you or your children are not feeling well.

發燒超過37.5度以上呼吸困難,喉嚨痛等 Fever of 37.5 degrees or above, Shortness of Breath, Sore Throat, etc.

沒有不舒服 None of the Above

您或您的家中成員，是否曾在2020年3月1號後與確診新型冠狀病毒的患者接觸? *

Have you or any member of your family ever been in contact with a patient diagnosed with the new coronavirus COVID-19 after March 1, 2020? / Have you or any member of your household ever been in contact with someone diagnosed with Coronavirus COVID-19 since March 1, 2020?

否 NO

是 YES

請注意不得隱匿旅遊活動史,不得隱匿自己或他人接獲「居家隔離通知書」,「居家檢疫通知」, 「自主健康管理通知書」的事實,若接獲前述通知書者,亦應主動誠實告知,不得隱瞞。Please note that the history of travel activities should be disclosed. The fact that you or others have received the "Home Separation Notice", "Home Quarantine Notice", and "Independent Health Management Notice" should also be fully disclosed.若悉知前述人員或特定人(含訪客)具上述感染風險,仍予以隱匿時,本空間可拒絕入場,拒絕接待,且無賠償責任;且若因前述行為導致本空間發生損害,應負損害賠償責任.If it is known that the aforementioned personnel or specific persons (including visitors) have the above-mentioned infection risk and are still dishonest, our studio may refuse any service, with no liability for compensation; and if the aforementioned behavior causes damage to our studio, the person responsible will reimburse our studio for any loss or damage.本人證明以上資訊皆屬實，若有任何變動將自動通知。 *

屬實

非屬實

日期date *

YYYY

其他任何相關問題?

Any other information related to your health that you would like to disclose?

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