7月「夜航看日出」報名表
一、基本資料 Personal Data
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裝備。謝謝!
Please provide complete information for insurance and other relevant matters
姓名 Name *
Your answer
出生年/月/日 *
birth yyyy/mm/dd
Your answer
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(腳掌長度)(單位:公分) *
Shoe size(Length of feet(*cm))
Your answer
戶籍地址 *
address
Your answer
聯絡電話 *
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
二、海洋休閒活動能力自我評估表
Marine Leisure Activities self-evaluation form
我的獨木舟經驗 *
Your answer
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)
衝浪(Wind-surfing)
風帆(Sailing)
風帆(Sailing)
其他活動
Other activities
Your answer
心理與生理狀態自我評估(我是否罹患或曾被診斷出以下之疾病) *
State of mind and physical condition self-evaluation form
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)
黑暗恐懼症(Nyctophobia)
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 *
Required
報名梯次 *
活動費用為每梯次新台幣5500元。(含活動所需師資、教案、船隻、設備、器材、餐費、住宿與人員保險等費用。)
Required
飲食習慣 *
Required
匯款帳號後5碼 *
報名完成後,請於3日內匯款,謝謝!
Your answer
若有任何問題,請留言,謝謝!
Your answer
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