KJS-Y6-1121

Asia Pacific Adventure

Unit B, 16/F, Gee Chang Hong Centre,

65 Wong Chuk Hang Road, Hong Kong

Tel: (852) 2792 7128

Youth Program Enrollment Form 2021

This information is being collected to enable our staff to more effectively respond to potential medical emergencies. Program participants or their parents/legal guardians must supply the requested information in order to take part in the program activities. All requested information will be used only for protecting the safety of the participants and will not be shared with others, except as necessary in order to protect participant's safety.

Please note:

1) Each participant is required to fill in this form for safety management purposes and to deal with incidents and emergencies efficiently. All information is strictly CONFIDENTIAL and will only be used for the program's safety management purposes.

2) For any participating minor (those that are under 18 years of age), this form should be signed by the minor's parent or legal guardian. The parent or legal guardian agrees that they and the minor are subject to all the terms of this enrolment form.

3) Please use ENGLISH to fill in the enrollment form.

4) The online enrollment form is provided by Jotform.com. Jotform Inc will never sell, share or otherwise distribute your customer's data to third parties. By completing the form means you accept Jotform Inc. Terms of Service and Privacy Policy. For any enquiries, please visit http://www.jotform.com

Declaration

I, the undersigned (referred to as the participant), declare that the information provided is true and complete. The participant agrees that their personal data may be used by Asia Pacific Adventure ("APA") and its staff for administration, programming and emergencies.

The participant 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 program. The participant understands and accepts that if the rules and safety regulations are not observed, the participant may be dismissed from the program and will be responsible for any costs incurred, including costs to return home.

The participant understands that the program involves physical activities. To the best of the participant's knowledge, there are no medical or other reasons for the participant not to take part in this program. The participant is in normal health with no undeclared pre-existing medical or psychological conditions, or allergies.

The participant agrees that while the staff of APA will exercise reasonable care and supervision, neither APA nor its staff, shall be held liable for any loss, damage or injury to person or property occasioned by irresponsible acts or behavior of the participant.

The participant understands that while the staff of APA will exercise reasonable care and supervision, there are elements of risk involved in some of the activities. APA will not be liable for any injuries or accidents and APA will be held blameless in and from all claims, liabilities, damages, costs and detriments not arising directly from APA’s actual negligence or malpractice in carrying out the agreed program.

The participant understands that the deposit once paid is non-refundable. Any cancellations that occur within 14 calendar days of the program delivery date will result in 100% of the total program fee being forfeited.

For overseas programs, the participant has been advised that travel insurance is required for the program and should be organized by the participant's school. The participant understands that APA will not reimburse for cancellations made for medical reasons. Cancellations due to medical emergencies should be claimed against travel insurance on production of medical certificate.

The participant agrees that APA will have the right to use the participant's footage/images/testimonials in its promotional material or any other materials relating to the program for marketing purposes. If participants do not wish us to use photos that include them, please advise us on the bottom of the enrolment form in the "Other Remarks" section.

Participant's Name*

First NameMiddle NameSurname

Date of Birth*

DayMonthYear

Gender*

Role*

TeacherStudent

Mobile Phone Number*

Area CodePhone Number

Year/Grade in School*

Nationality

Hong Kong Identity Card Number or Passport Number (if you do not have a HKID or for Overseas Programs)*

Address *

Street Address

Street Address Line 2

Country

1) Emergency Contact Name*

First NameLast Name

1) Relationship to Participant (i.e. Mother)*

1) Emergency Contact Phone Number*

2) Emergency Contact Name

First NameLast Name

2) Relationship to Participant (i.e. Father)

2) Emergency Contact Phone Number

Does the participant have any relevant medical, physical or psychological condition(s), which the program leader should be aware of?*

NoYes

If yes, please provide further details including medications and dosage. as well as any treatment(s) undertaken/undertaking

Does the participant have any allergies and/or special dietary requirements which the program leader should be aware of?*

NoYes

If yes, please provide further details including allergens, reactions, medications etc.

Does this allergy require an Epi-pen?*

NoYes

If yes, please be reminded to pack two sets of Epi-pens for the program

Has the participant been in the hospital in the last 12 months for any serious injury or illness?*

NoYes

If yes, please explain

Doctor's Name and Phone Number:

For overseas programs, please be advised to consult your doctor regarding any vaccinations you may need for travelling outside the country.

I the undersigned give consent to the Asia Pacific Adventure (APA) staff (First Aid Qualified) to administer the following non-prescription medications to the participant if deemed necessary.

Paracetamol (used to treat common headache and minor pains).*

NoYes

Imodium (used to treat diarrhoea).*

NoYes

Antihistamines like Antihisan or Piriton (used to treat minor skin irritations like mosquito bites).*

NoYes

APA Outdoor Shop

Address: 16A Gee Chang Hong Centre, 65 Wong Chuk Hang Road, Hong Kong
Opening Hours: Mon to Fri (11:00 am - 7:30 pm) and Sat, Sun, Public Holidays (11:00 am - 6:00 pm)
Telephone: (+852) 3153 4091
Email:  customer@apaoutdoorshop.com
Website:  www.apaoutdoorshop.com
Directions:  www.apaoutdoorshop.com/service/location/

Participant's Name

First NameLast Name

Participant's Signature*

Parent or legal guardian must sign for any participating minor (those that are under 18 years of age) and agree that they and the minor are subject to all the terms of this document as above.

Parent or Legal Guardian's Name

First NameLast Name

Parent or Legal Guardian's Signature*

E-mail Address*

Confirmation EmailA signed copy of waiver will be sent to the address you provide

Check appropriate box below if you are interested in receiving our marketing emails.*

Please add my email address to your mailing list.Do not add my email address to your mailing list.

Other Remarks

Personal Information

Emergency Contacts

Medical Information

Administration of Non-prescription Medications

Electronic Signature Consent*