☸️ Texas Pagoda Chan Monastery Visitors Registration Form 德州寶塔禪寺訪客登記表
     Please fill out the following form to register to visit Texas Pagoda Chan Monastery. If you would like to bring friends, please ask them to register as well. Once you submit the form, WE WILL REVIEW AND CONTACT YOU WITH A CONFIRMATION BY EMAIL.
    欲參訪德州寶塔禪寺的居士,請填寫下列表格。若您有朋友們想一同參訪,也請他們個別填寫。提交表格後,我們將審核並透過電子郵件與您聯繫並確認。

     Please review these COVID-related restrictions. We would ask you to delay your visit if any of the following are false.
    請查看這些與新冠病毒相關的限制。如果您對以下任何陳述回答「否」,我們請您延後您的參訪日期。

1. I have not recently experienced any of the following symptoms: fever of 100.4F or greater, cough, sore throat, shortness of breath or difficulty breathing, chills, muscle aches, headache (not attributed to a chronic condition such as a migraine), new loss of taste or change in taste or smell, or other symptoms of illness.
我最近沒有以下症狀: 發燒超過華氏100.4度,咳嗽,喉嚨痛,氣短或呼吸困難,發冷,肌肉酸痛,頭痛(非慢性疾病所引起的頭痛如偏頭痛),最近剛發生味覺的喪失或有味覺、嗅覺的改變。其他感冒症狀。

2. I have not been in close contact with anyone who has been confirmed positive for COVID-19 within the past 14 days.
在過去14天內,我沒有與新冠肺炎確診的患者有過近距離的接觸。

3. I have not been in close contact with anyone who is experiencing symptoms of COVID-19 but is not yet to be confirmed within the past 14 days.
在過去14天內,我沒有與有新冠肺炎症狀但尚未確診的人員有過近距離的接觸。

4. I have not been instructed by a health care provider or public health authority to be under home quarantine within the past 14 days.
在過去14天內, 沒有醫療提供者或公共衛生機關指示我在家隔離。

5. I have not been confirmed positive for COVID-19 in the past 14 days.
在過去14天內,我沒有確診罹患新冠肺炎。

6. I have not traveled outside the country or on an airplane within the past 14 days.
在過去14天內,我沒有出國亦或搭乘國內或國外班機。

7. I agree to the Pagoda Chan Monastery's requirements, including: wearing masks, social distancing, taking of temperature, filling out questionnaire and consent form. I also agree that I voluntarily assume the risk that I may be exposed to or infected by COVID-19 in the Pagoda Chan Monastery and I waive any liability against the Pagoda Chan Monastery and any other parties.
我同意遵守德州寶塔禪寺之戴口罩,保持社交距離,量體溫,填寫健康聲明書等防疫措施。我也同意自願承擔我在德州寶塔禪寺中可能接觸或感染新冠肺炎的風險,並且放棄要求德州寶塔禪寺或其他方的任何法律責任。

Thank you for your cooperation! 感謝您的配合! 🙏🏻
Sign in to Google to save your progress. Learn more
By agreeing, you affirm that the above statements are true. 點選「我同意」代表我確認以上的陳述都是真實無誤的。 *
Required
Name 姓名 *
Email 電子郵件信箱 *
Phone Number 電話號碼 *
The date you would like to visit 您想參訪的日期 *
MM
/
DD
/
YYYY
The time you would like to visit 您想參訪的時段 *
Currently open from 2pm to 5pm! 目前開放的時間為下午兩點到下午五點!
Time
:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy