葵青社區重點項目預防流感疫苗注射服務2018

收集個人資料聲明 Personal Information Collection Statement

1)
在本表格內提供的個人資料乃屬自願性質。根據《個人資料(私隱)條例》，在本表格所填寫的個人資料，只會用作處理服務用途，包括登記、聯絡、報告和統計，亦只限授權人員方可查閱有關資料作前述目的之用。
The provision of personal data in this application form is voluntary. In accordance with the Personal Data (Privacy) Ordinance, the personal data provided in the application form will be used for the enrollment, registration, communication and statistics. It will only be accessible to authorized officers for the said purposes.

2)
申請人如欲獲得或更改其個人資料，請致電聯絡葵青安全社區及健康城市協會。
[ 本會地址及查詢電話 ]
地址: 葵涌荔景邨日景樓低層二樓一號舖
電話: 2436 3363
Enquiries concerning the personal data collected by means of this form, including the making of access and corrections, should be addressed to Kwai Tsing Safe Community and Healthy City Association (KTSCHCA).
[ Address and Contact number of KTSCHCA ]
Address: Shop No.1, LG 2/F, Yat King House, Lai King Estate, Kwai Chung
Tel: 2436 3363

3)
如有需要，請在上方填寫電郵地址作聯絡及寄送所填寫的表格副本之用。
Please provide your email address on the above for the purpose of contact and obtain a copy of your personal data as provided in this form, if it is needed.

申請資格 Eligibility Requirement

1.
申請者必須符合以下三項資格方能成功申請服務，包括：
a) 年齡介乎12至49歲；
b) 現居住址為葵青區；
c) 不是「疫苗資助計劃」及「政府防疫注射計劃」之受惠人。
Applicant must fulfill the following THREE requirements, which include:
a) Age between 12-49 years old:
b) Must be a Kwai Tsing Resident；
c) Do not benefit from the Government Vaccination Programme (GVP) and the Vaccination Subsidy Scheme (VSS).

2.
申請者須在接受服務當天填寫正確無誤的地址。
Applicant must provide a detailed and accurate address on the service day.

3.
「疫苗資助計劃」及「政府防疫注射計劃」詳情請瀏覽: https://goo.gl/rkfWJW
For details of the Vaccination Subsidy Scheme (VSS) and Government Vaccination Programme (GVP), please check: https://goo.gl/MU2jGo

本服務只提供給予12-49歲人仕 The service is only provided for the age between 12 to 49 years old

申請者必須為葵青區內居民 Applicant must be a Kwai Tsing Resident

如對所居住之所屬區份不清楚，請參閱葵青區分界地圖: https://goo.gl/UmhQMB

「疫苗資助計劃」及「政府防疫注射計劃」之受惠人不能申請本服務 People who are eligible for the Government Vaccination Programme (GVP) and the Vaccination Subsidy Scheme (VSS) cannot apply for this service.

是 Yes
否 No

申請者只能在下列場次中選擇一場 / Choose one ONLY

申請人聲明 / Declaration by Applicant

本人謹此聲明－

以上填報的個人資料正確無誤，亦明白葵青安全社區及健康城市協會對於是否接納報名申請擁有最終決定權。

I declare that－
all information given in this application form is correct, complete and true. I understand that the Kwai Tsing Safe Community and Healthy City Association reserves the right to accept or decline the application. Should there be any dispute, the Kwai Tsing Safe Community and Healthy City Association reserves the right to the final decision.

報名截止
報名名單已額滿及截止。如有查詢，請致電2436 3363 與協會職員聯絡。