Kiwassa Senior Programs - Membership Registration Form April 2021 -March 2022 (奇华沙耆英组-会员登记表)2021年4月到2022年3月
All seniors (including old members),program participants and seniors who are accessing our services (e.g. phone check-in, food hamper delivery, art box delivery..etc) are required to fill out this membership form.

You may ask a staff or someone to fill out this form for you if you are experiencing any technical difficulties.
如果您遇到任何技术上的困难,可以叫我们的员工或其他人帮您填 这张表格。

For all new members, a staff will send you a welcome email and contact you after you've registered.

*You are only required to answer the questions with red star(*). For other questions, you have the option to choose if you want to answer. The purpose of answering these questions could help us better support you, so if you could answer more questions, that would highly appreciated! 您只需要回答带有红色星号(*)的问题即可。对于其他问题,您可以选择是否要回答。回答这些问题的目的可以帮助我们更好地为您提供服务,因此,如果您可以的话,请尽量回答更多的问题,将不胜感激!

*All the information that you give us will only be shared within our senior program staff team (Cherrie & Giovana). We will not give your information to other people without your permission unless there is a life-threatening situation. *您提供给我们的所有信息只会在我们的耆英部门的员工(Cherrie&Giovana)中共享。除非存在危及生命的情况,否则未经您的允许,我们不会将您的信息提供给其他人。

*Please remember to read and consent to the terms "ACCEPTANCE OF RISK, AND CONSENT " on the bottom of the page!请记得阅读和同意页面底部“接受风险并同意”的条款!

*Please remember to click "submit" on the bottom of the page when you have completed the form. 请记得填完表格后,在页面底部点击“Submit” 递交“。
Sign in to Google to save your progress. Learn more
Name (First & Last) 姓名: *
Date of Birth (if you want us to send birthday greeting message to you) 出生日期(如果您想让我们发生日祝福的短信给您的话)
Email 电子邮件:
Phone Number 电话号码: *
Home Address 家庭地址: *
Emergency Contact Person & Phone Number 紧急联络人和电话号码: *
What is your relationship with your emergency contact? 您与您的紧急联络人是什么关系呢? *
Are you a new member or you are renewing your membership?                                                                                您是新的会员还是更新您的会员身份? *
1. Do you live alone? 您是自己一个人住吗?
Clear selection
2. To help us better support you, what are some challenges that you are currently experiencing? (check all that apply)  为了让我们可以更好的支持您,您目前正在经历哪些挑战/困难呢?(将所有适用都打勾✔)
3. Do you have any allergies that we need to know? 您有什么我们需要知道的过敏症吗?
4. Do you have any dietary restrictions/preference? 您有饮食上的限制(忌口)/喜好吗?
5. Can Kiwassa publish your photo on promotional material, our website, and social media?奇华沙可以在宣传材料,我们的网站和社交媒体上发布您的照片吗? *
6. What is your primary language? 您的母语是?(*Only new members need to answer 只有新会员需要回答)
Clear selection
7.How did you hear about us? 您是怎么知道我们的?(*Only new members need to answer 只有新会员需要回答)
8. Which of the following services are you looking for? 您在寻找以下的哪些服务呢?(*Only new members need to answer 只有新会员需要回答)
9. Which of the following online group activities/classes you would like to participate in? 您对以下的哪个在线课程和活动感兴趣?(*Only new members need to answer 只有新会员需要回答 )
Which of the following in-person activities will you be interested to participate in? 以下哪些面对面活动是您感兴趣的?Please note that clicking the activities here doesn't guarantee that you will be registered for the activity. It's just asking about the activities that you will be interested in attending. You will also need to complete another form called "In-person activity registration form" for registration to the activity below.(*Only new members need to answer 只有新会员需要回答 )请注意,您在这里打钩的活动不能保证您可以注册到那个活动。这里只是问您有兴趣想参加的活动。如果您要登记以下的其中一个活动,请在另外的"实体活动登记表格”上注册。
10. *ACCEPTANCE OF RISK, AND CONSENT:                                           I acknowledge that there are risks, dangers, and hazards associated with my participation in Kiwassa programming, including online programs, including, but not limited to: impact and collision with other participants during recreation activities; contraction of a contagious disease including, but not limited to, COVID-19; adverse weather conditions; loss of balance; falling;  failure to participate in activity safely within one's own ability; consumption of food and drink, whether made by professionals or by non-professionals; and negligence of other participants or Kiwassa staff. Participants are expected to be respectful and considerate towards other participants, Kiwassa staff including all instructors, and external partner organization instructors. Participants are expected and required to follow the directions of all instructors.                                                                                                                                                                                 MEDICAL EMERGENCIES: In the event of an accident, injury or illness involving the registrant, and immediate contact by Kiwassa with a designated contact cannot be made, I hereby authorize and grant permission to Kiwassa staff to secure proper medical treatment and authorize on the registrant’s behalf all procedures, including, without limitation, admission to an emergency unit, hospital and treatment therein, ordering of x-rays, tests or treatment, injections, anesthesia and/or surgery, as deemed necessary by the attending medical professional(s). I agree not to hold Kiwassa responsible for any costs or injury arising out of an emergency situation.                                            接受风险并表示同意:                                                                  我知道参与Kiwassa的活动(包括在线课程)存在一定的风险和危险,包括但不限于:娱乐活动期间与其他参与者的碰撞;传染性疾病的收缩,包括但不限于COVID-19;不利的天气条件;失去平衡;跌倒;无法在自己的能力范围内安全地参加活动;食品和饮料的消费,无论是由专业人员还是由非专业人员进行的;以及其他参与者或Kiwassa工作人员的疏忽。希望参与者对其他参与者,包括所有讲师在内的Kiwassa的工作人员以及外部合作伙伴组织的讲师表示尊重和体谅。期望并要求参与者遵循所有课程的讲师的指示。                                                         紧急医疗事故:如果发生事故,受伤或生病,并导致注册人无法立即与紧急联系人取得联系,我特此授权Kiwassa工作人员并确保其得到适当的治疗,并代表注册人授权所有程序,包括但不限于,急诊医疗专业人员认为必要的,包括进入急诊室,医院及其中的治疗,照X光片,进行检查或治疗,注射,麻醉和/或手术。我同意不 对Kiwassa承担因紧急情况引起的任何费用或伤害负责。 *
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy