Island.edu.hk

ENROLLMENT FORM
This information is being col ected to enable our staff to more effectively respond to potential medical emergencies.
Program participants or their guardians must supply the requested information in order to be able to take part in the
program activities. All requested information will be used only for protecting the safety of the participants and will notbe shared with others, except as necessary in order to protect participant’s safety.
Please note:
1. Each applicant should complete this form in BLOCK LETTERS.
2. If the applicant is under 18, signature of a parent or legal guardian is required.
3. Please tick (√ ) the appropriate box when applicable.
4. Information on this form is crucial to us for emergency situations and quality program planning. This form is considered valid only with complete information.
Course Name _____________________________________________________________________ School/Organization ________________________________________________________________ I. Participant Information
Passport #_____________________________ ID#___________________ II. Parent/ Guardian Information
Asia Pacific AdventureUnit B, 16/F, Gee Chang Hong Centre,65 Wong Chuk Hang Road, Aberdeen, Hong KongTel: 852-2792-7128Fax: 852-2792-9146 III. Emergency Contacts*
*Additional people who have authorization to grant permission for medical or surgical intervention
in the event that mother / father / legal guardian cannot be contacted.
IV. Past Medical History
1 Does student have any relevant medical, physical or psychological condition(s), which the course 2 Is student under medical treatment or prescribed medication? *(If yes, please ensure student has adequate supplies of this medication on the program.) Treatment/ medication: ________________________________________ Reason medication / treatment was prescribed: 3 Does student have any al ergies which the course leader should be aware of? 5 If student has a nut al ergy, please select from the fol owing: al ergy to EATING any food containing nuts(eg. granola bars)or nut products(eg. cooked with peanut oil) al ergy to AIRBORNE particles of nuts (eg. sitting next to someone eating food containing nuts) 6 Does student have any special dietary requirements? 7 Has student been in the hospital in the last 12 months? 8 Doctor’s Name and Contact Number: ____________________________________________________ 9 If necessary, please use this space to record the type and quantity of ANY medications student is Asia Pacific AdventureUnit B, 16/F, Gee Chang Hong Centre,65 Wong Chuk Hang Road, Aberdeen, Hong KongTel: 852-2792-7128Fax: 852-2792-9146 Administering non-prescription medications
I the undersigned give consent to the Asia Pacific Adventure Ltd,(APA) Program Coordinator(First Aid
Qualified) to administer the fol owing non-prescription medications to the participant if jointly deemed
necessary by both the APA Program Coordinator and the Lead School Teacher attending the program.
Please place a check mark (√) in the box and initial to indicate approval of the administration of the medication to the participant.
_____________ Initial. Paracetamol (used to treat common headache and minor pains).
_____________ Initial. Charcoal tablets or Imodium(used to treat upset stomach and diarrhea). _____________ Initial. Antihistamines like Anthisan, or Puriton (used to treat minor skin irritations like mosquito bites).
_____________ Initial. Prickly Heat Powder (Commonly used for treatment of heat rash). V. Declaration
1. I, the undersigned (referred as “the applicant”), declare that the information provided is true and
complete. The applicant agrees that the personal data of the applicant may be used by Asia PacificAdventure Ltd. (referred as “APA”) and its staff for administration, programming and emergencies.
2. The applicant agrees to abide by the rules for taking part in this program, as well as to participate fully and cooperatively with others while on the course. The applicant understands and accepts that if therules are not observed, the applicant may be dismissed from the course.
3. The applicant understands that the course involves physical activities. To the best of the applicant’s knowledge, there are no medical or other reasons for the applicant not to take part in this course. Theapplicant is in normal health with no undeclared pre-existing medical or psychological conditions, oral ergies.
4. The applicant agrees that while the staff of APA will exercise reasonable care and supervision, neither APA nor its staff, shal be held liable for any loss, damage or injury to person or property occasionedby irresponsible acts or behavior of the applicant.
5. The applicant understands that while the staff of APA will exercise reasonable care and supervision, there are elements of risk involved in some of the activities and that APA will not be liable for anyinjuries or accidents.
6. I agree that APA will have the right to use my footage/ images/testimonials in its promotional material or any other materials relating to the program for marketing purposes. 7. The applicant understands that the deposit (50% of total program fee) once paid is non-refundable and for cancel ation within 2 weeks of the course delivery date, 100% of the total program fee isforfeited. Full cancel ation coverage up to the day of course commencement (on receipt of a doctor’scertificate) for local courses is available through our parent company, APA group. Please check withyour school if you have not already received details. Parent / Legal Guardian’s Agreement (For Applicant under 18):
I, the undersigned, am the parent / legal guardian of the above applicant. I have read and agreed to thedeclaration in Part V above and agree for the above applicant to take part in the above course. * I am interested in learning about future Asia Pacific Adventure programs. Please add my e-mail address to your mailing list.
Asia Pacific AdventureUnit B, 16/F, Gee Chang Hong Centre,65 Wong Chuk Hang Road, Aberdeen, Hong KongTel: 852-2792-7128Fax: 852-2792-9146

Source: http://www.island.edu.hk/sites/island/files/youth%20enrollment%20form%20V.2-HK%20(1).pdf