2016國際不老水手清水斷崖挑戰賽報名表
(Registration Form)
報名者關係 *
Member Relationship
Your answer
基本資料(Personal Data ( per person ))
(請詳實填寫,以便主辦單位為您辦理保險及準備海洋活動所需之服裝、道具。謝謝!)
每組兩人,合計年齡需=或>100歲。
( Please provide complete information for insurance and other relevant matters)
組別名稱 (自取) *
Team name
Your answer
姓名一 *
register 1
Your answer
出生年月日 *
birth
MM
/
DD
/
YYYY
性別 *
sexial
身份證字號 *
ID(Passport) Number
Your answer
身高 *
height (*cm)
Your answer
體重 *
wight (*kg)
Your answer
鞋子尺寸(shoe size) *
(腳掌長度)(Length of feet (*cm))
Your answer
戶籍地址 *
address
Your answer
連絡電話 *
Telephone numbers
Your answer
E-Mail
Your answer
緊急聯絡人 *
Emergency Contact Person (name)
Your answer
緊急聯絡人關係 *
relationship
Your answer
緊急聯絡人電話 *
Emergency contact number
Your answer
保險受益人 *
Insurance Beneficiaries
Your answer
保險受益人關係 *
relationship
Your answer
保險受益人電話 *
Beneficiaries number
Your answer
海洋休閒活動能力自我評估表
Marine Leisure Activities self-evaluation form
我的游泳能力是 *
Swimming
我曾經從事以下之海洋休閒活動 *
My experiences in the following activities
毫無經驗(Never)
略有經驗(Some)
普通(Average)
良好(Good)
精通(Excellent)
海泳(Swimming in the sea)
浮潛(Snorkeling)
水肺潛水(Scuba diving)
獨木舟(Kayaking)
衝浪(Wind-surfing)
風帆(Sailing)
動力小船(Motor boats)
其他活動(Other activities)
Please describe other activities
Your answer
登山活動能力自我評估表 *
Mountain climbing experiences self-evaluation form
毫無經驗(Never)
略有經驗(some( 100m))
(登過1000m 高山) 良好(Average(1000m))
(登過3000m 高山) 精通(good (3000m))
相當於高山嚮導員(excellent)
我的登山能力是(My experiences in mountain climbing)
心理與生理狀態自我評估(State of mind and physical condition self-evaluation form) *
我是否罹患有(或曾被診斷出)以下之疾病
有(yes)
無(no)
憂鬱症(Depressing)
癲癇症(Epilepsy)
心肺功能異常(例如氣喘、心律不整等)(Arrhythmia(ex.Asthma))
曾接受重大開刀手術(Major surgery )
以上若有一項為”有”,請詳述其內容於下:
If yes, please describe the sydrome
Your answer
報名項目 *
Program selected
姓名二 *
register 2
Your answer
出生年月日 *
birth
MM
/
DD
/
YYYY
性別 *
sexial
身份證字號 *
ID(Passport) Number
Your answer
身高 *
height (*cm)
Your answer
體重 *
wight (*kg)
Your answer
鞋子尺寸(shoe size) *
(腳掌長度)(Length of feet (*cm))
Your answer
戶籍地址 *
address
Your answer
連絡電話 *
Telephone numbers
Your answer
E-Mail
Your answer
緊急聯絡人 *
Emergency Contact Person (name)
Your answer
緊急聯絡人關係 *
relationship
Your answer
緊急聯絡人電話 *
Emergency contact number
Your answer
保險受益人 *
Insurance Beneficiaries
Your answer
保險受益人關係 *
relationship
Your answer
保險受益人電話 *
Beneficiaries number
Your answer
海洋休閒活動能力自我評估表
Marine Leisure Activities self-evaluation form
我的游泳能力是 *
Swimming
我曾經從事以下之海洋休閒活動 *
My experiences in the following activities
毫無經驗(Never)
略有經驗(Some)
普通(Average)
良好(Good)
精通(Excellent)
海泳(Swimming in the sea)
浮潛(Snorkeling)
水肺潛水(Scuba diving)
獨木舟(Kayaking)
衝浪(Wind-surfing)
風帆(Sailing)
動力小船(Motor boats)
其他活動(Other activities)
Please describe other activities
Your answer
登山活動能力自我評估表 *
Mountain climbing experiences self-evaluation form
毫無經驗(Never)
略有經驗(some( 100m))
(登過1000m 高山) 良好(Average(1000m))
(登過3000m 高山) 精通(good (3000m))
相當於高山嚮導員(excellent)
我的登山能力是(My experiences in mountain climbing)
心理與生理狀態自我評估(State of mind and physical condition self-evaluation form) *
我是否罹患有(或曾被診斷出)以下之疾病
有(yes)
無(no)
憂鬱症(Depressing)
癲癇症(Epilepsy)
心肺功能異常(例如氣喘、心律不整等)(Arrhythmia(ex.Asthma))
曾接受重大開刀手術(Major surgery )
以上若有一項為”有”,請詳述其內容於下:
If yes, please describe the sydrome
Your answer
報名項目 *
Program selected
匯款帳號後5碼 *
Bank Account number ( last five digit )
Your answer
Submit
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