NCA 2020 Masks RSVP Form

Dear Applicant,

If you are interested in disposable masks, please submit this RSVP form before 05/24/2020. Each family can only request up to one (1) package of disposable(non-surgical) masks. Each package has 50 pieces of masks.

Due to limited quantities, these disposable masks will be provided to NCA donors, NCA members, and Chinese nationals who reside in Nebraska (must be 65 years old or older, must present a Government-issued Chinese passport that includes the recipient’s name), on a first come, first served basis. We will provide you the instruction of how to pick up the masks, after we close the form.

If you have any questions, please contact us at OmahaChinese@gmail.com. Thank you.

-Nebraska Chinese Association (NCA)

尊敬的申请人:

如果您需要民用口罩, 请您在5月20日前填写以下预约表。

申请条件(符合以下其中的一个条件即可):

1. NCA2020年捐款者 (参加了2020内布拉斯加州春晚募捐、援助中国医务工作者、援助内布拉斯加州医务工作者这三场募捐活动中的任何一场)
2. NCA会员(持有NCA 2020年会员卡)
3. 居住在内布拉斯加州的65岁或65岁以上的中国公民(领取防护用品时需出示护照)。

每个家庭最多只能领取一盒(五十个装)民用口罩。数量有限,先到先得。

领取口罩的时间和地点将另行通知。

谢谢!

-内布拉斯加州华人协会
Email address *
First Name 您的名字(请用英文或拼音格式填写) *
Your answer
Last Name 您的姓氏(请用英文或拼音格式填写) *
Your answer
Phone Number 您的联系电话
Your answer
I am 我是 *
NCA 2020 Member (会员)
NCA 2020 Donor ( 捐款者)
NCA 2020 Donor and Member (会员和捐款者)
Chinese national who are 65 years old or older (一名65岁或65岁以上的中国公民)
我是
Comment/Note
Your answer
NCA 2020 membership number 会员卡号码
Your answer
Waiver
Donated Items:50 disposable masks

Recipient hereby acknowledges the receipt of donated items (“Equipment”) described above
from the Nebraska Chinese Association (NCA), a Nebraska non-profit organization. NCA
donates Equipment at no charge to Recipient; Recipient voluntarily and knowingly accepts
Equipment “AS IS”.

NCA makes no representation or warranties whatsoever, expressed or implied, regarding the
Equipment. Recipient understands that there are certain risks of injury, sickness, disability, or
death to person or property could arise from the possession, use, and misuse of the Equipment.
Receipt assumes such risk and releases NCA from any liability or responsibility for any injury,
damage, sickness, death, however caused, directly or indirectly, in connection with the
Equipment. Furthermore, Recipient agrees to indemnify NCA and hold it harmless from and
against all liability, claims causes of actions, and costs of whatsoever kind and nature including,
without being limited to injury, damage, sickness, death, resulting from, arising out of, or
occurring in connection with the donated Equipment.

I have read and understood this Receipt and Waiver. I voluntarily consent to this agreement and
agree that if any part is held invalid, the remaining parts will remain in full force and effect. I
further agree that the choice of law shall be governed by the laws of the State of Nebraska and
venue shall be in the State of Nebraska.
*
My Name (Full Name) *
Your answer
Today's Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy