Summer Fun@PolyU 2017 Registration Form

0 downloads 191 Views 318KB Size Report
Please complete and return the “Registration Form”, together with payment for registration fees, .... (name of parti
Summer Fun@PolyU 2017 Registration Form Important Notes 1. Please complete and return the “Registration Form”, together with payment for registration fees, to The Hong Kong Polytechnic University. Address: Alumni Affairs and Development Office, Room M1504, 15/F Li Ka Shing Tower, The Hong Kong Polytechnic University, Hung Hom, Kowloon. Email: [email protected] Enquiry Tel. No.: 2766-4102 Fax No.: 2954-0315 2. Registrations received without payment will not be processed. 3. Confirmation emails will be sent to successful registrants prior to the activity. Registration fee is non-refundable once the registration is accepted. 4. Each alumnus can bring a maximum of 2 children to join each programme. The parents/guardians of participants aged below 18 must sign the “Parent/Guardian Authorization Form”. If any participants fail to submit this form, the organisers reserve the right to refuse him/her from participating in the activities. Programmes for Registration Please  as appropriate

Registration fee

Sub-total



HK$70 (adult) HK$50 (age 8 – 17)

HK$

HK$150 (adult) HK$100 (age 12 – 17) (include transportation and travel insurance) HK$180 (adult) HK$150 (age 12 – 17) (include transportation and travel insurance) HK$70 (adult) HK$50 (age 10 – 17)

HK$







22 July (Sat) 10:00am – 12:30pm Anti-Mosquito Sachet Workshop & Guided Tour to PolyU’s House of Innovation 29 July (Sat) 8:00am – 2:00pm Hong Kong Fishermen Culture & Eco Tour – Northeast New Territories [mangrove site, mariculture raft and demonstration on fishing methods] 12 August (Sat) 8:30am – 1:00pm Low Carbon Diet Workshop @ Green Hub [harvest seasonal herbs, interactive activities such as food preparation and post-meal waste treatment, heritage tour] 19 August (Sat) 10:00am – 12:30pm Upcycling Artwork Workshop & Guided Tour to PolyU’s Eco-friendly Facilities [transform unused waste to handicraft artwork, campus guide tour]

HK$

HK$

Total HK$ 0.00 Disclaimer: I/ We would like to join the “Summer Fun@PolyU 2017” programmes, and declare that: I/ We will follow all the rules and arrangement imposed by the event organizers on the programmes. I/ We confirm that I am / we are suitable for the activity and will bear all the responsibilities, including deaths, injuries, or loss of properties caused by any accidents or incidents during the programmes. No organizer(s), co-organizer(s), sponsor(s) or supporting organization(s) or their working staff have to compensate for the deaths, injuries, or loss of properties caused by any accidents or incidents during the programmes. Participant (Alumni) 1st Child 2nd Child Name (Eng) Name (Chi) Age Graduation Year Graduation Department Mobile Phone No Email address Emergency Contact Person/ Phone No. Signature Payment Method Please  as appropriate By Cheque (Please make the cheque payable to “The Hong Kong Polytechnic University”) Signature By Credit Card PolyU Visa Card VISA MasterCard Name of Card Holder Amount HK$ 0 Card Number Expiry Date (MM/YY) Personal Information Collection Statement To ensure that you are informed of PolyU’s latest developments, we will send news and announcements of the University (and its internal departments and constituent units) and other information (including information about activities, benefits and services, education programmes and solicitation of donations) to you through various communication channels by using your personal data provided (including email address, mailing address, contact telephone number and fax number). We will not use your personal data for sending the said information to you without your consent, and if you want to have access to or change your personal data, please contact the Alumni Affairs and Development Office of PolyU at Tel: (852) 2766 4102/ Fax: (852) 2945 0315/ Email: [email protected]. If you do not agree to our use of your personal data for the above-mentioned purposes, please let us know by putting a “√ ” in this box: 

1

Summer Fun@PolyU 2017 Parent/ Guardian Authorization Form Programme (please  as appropriate)  22 July (Sat) Anti-Mosquito Sachet Workshop & Guided Tour to PolyU’s House of Innovation  29 July (Sat) Hong Kong Fishermen Culture and Eco Tour – Northeast New Territories  12 Aug (Sat) Low Carbon Diet Workshop @ Green Hub  19 Aug (Sat) Upcycling Artwork Workshop & Guided Tour to PolyU’s Eco-friendly Facilities Declaration 1/ I hereby agree ____________________ (name of participant aged below 18) to participate in the above mentioned programme(s). I certify that he/ she has acknowledged the content of the above programmes and his/ her health condition is suitable for the programmes. The organisers shall not be liable for any loss if the cause of the loss is due to the participant’s own negligence, inadequacy in health or fitness, omission of any information he/ she would provide in the registration form. Please list out the special health condition (e.g. allergy, asthma etc) of the participant here, if any: ____________________________________________________________________________________ ____________________________________________________________________________________ 2/ I assure that the participant will follow all the rules and arrangement imposed by the event organisers on the programme(s). He/ she is suitable for the activity and the adult accompanying him/her during his/her participation in the programme(s) will bear all the responsibilities, including deaths, injuries, or loss of properties caused by any accidents or incidents during the programme(s). No organizer(s), co-organizer(s), sponsor(s) or supporting organisation(s) or their working staff have to compensate for the deaths, injuries, or loss of properties caused by any accidents or incidents during the programme(s). *Parent / Guardian’s Signature: ______________________ Date: _______________________________ Name of Parent / Guardian: _____________________Emergency Contact No.: ____________________ (in block letters) *Please delete as appropriate Remarks 1. The personal data and other related information provided in the registration form will be used by the organisers for dealing with the application for participating in the programmes and other related purposes. The provision of personal data and other related information by means of the application form is voluntary. However, we may not be able to process the application if no accurate or adequate data is provided. 2. This form will be destroyed 2 months after completion of the programme.