由本處填寫For Office Use 	
會員編號Membership No.		
收據編號Receipt No.		
支票號碼Cheque No.		
繳費日期Date of Payment		

       康樂及文化事務署 	Leisure and Cultural Services Department
水上活動會員計劃        Water Sports Membership Scheme

會員申請表格Enrolment Form
(影印本同樣接受Photocopy of this form is acceptable)

此表格適用於申請成為康樂及文化事務署水上活動會員計劃的會員。會員證有效期由每年四月一日起至翌年三月三十一日。參加辦法請參閱康樂及文化事務署水上活動計劃之章程或致電2665 3591查詢。
This form can be used for application for enrolment as member of Leisure & Cultural Services Water Sports Membership Scheme.  Membership is valid from 1 April of the current year to     31 March of the following year.  Please refer to the prospectus of the scheme for details.  For enquiry, please call 2665 3591.
個人資料
1.	你提供的資料只供申請參加本計劃、統計、日後聯絡及宣傳本署活動之用。你提供的個人資料，除獲本署授權的職員外，將不會提供予其他人士。除在副本上特別申明外，本署不會退還你所提供的身份證明文件副本。當本署完成有關申請後，它便會被銷毀。
2.	若要求更正或索取你所申報的個人資料，請致電2664 5561與大美督水上活動中心經理聯絡。
3.	你必須提供本表格所需的個人資料(惟’職業’一欄可選擇填與否)，否則，本署可能無法處理你的申請。
Personal Data
1.	The information provided will only be used for the Water Sports Membership Scheme enrolment, statistical analysis, further correspondence, and promotion of activities organized by the Department.  Apart from staff duly authorized by the Department, no one will be given access to your personal information.  Unless otherwise specified, copies of personal identity documents will be destroyed upon completion of the application procedure.
2.	If you want to make access to and correction of your personal data, you may contact the Centre Manager of Tai Mei Tuk Water Sports Centre at 2664 5561.
3.	The provision of your personal information in this from is obligatory. (except the item’occupation’)  If not, the Department may not be able to process your application. 
(一)申請人資料(若申請人為上年度會員則只須填寫會員證號碼及需要更改的個人資料)
(1) Particulars of Applicant: (For renewal of membership, you only need to fill in the existing membership card no. and information which you want to update)
中文姓名(Chinese Name):	英文姓名(English Name):				

Existing Membership No.
會員證號碼_______________________

	
職業類別代號Occupation Code:	
學生Student-１	在職人士 Employed-２	
主婦 Housewife-３	退休人士 Retired-4	
其他Others-５		

身分證明文件號碼(I.D. No.):	性別(Sex):					
出生日期(Date of Birth):	職業(Occupation):				
通訊地址(Correspondence Address):						
電話號碼(Telephone No.):	(辦公室Office)				(住宅Home)
電郵地址(E-mail Address): 								
*若選擇以電郵方收取會訊，請填此欄
(Member who wants to receive Newsletter by e-mail method please fill in this column)  
(如遇緊急事故，請與				聯絡，電話:				)
(In case of emergency, please notify 		at 	)
水上活動資歷(只須填寫該項活動的最高資歷及附上有關證書的副本)：
Water Sports Qualifications (Please fill in the highest attainment and attach copies of certificates):
Item類別	Highest Qualification
最高資歷	Year Attended
考取年份	Issuing Organization
發證機構	Remarks
備註	
Kayaking獨木舟					
Sailing風帆					
Windsurfing滑浪風帆					
Others其他					
(二)聲明：(所有申請人必須填寫此欄) 
(甲)	年滿18歲或以上的申請人須填寫此聲明。
1.	我聲明我能游最少50公尺及身體並無任疾病，令我不宜參加上述計劃。如果因本的疏忽或健康或體能欠佳，而引致於參加這計劃的活動時傷亡，康樂及文化事務署則無須負責。
簽名:		日期:		
(乙)	未滿18歲的申請人，需由#家長/監護人或經其家長/監護人授權者填寫此聲明。
2.	本人同意			  (申請人姓名)參加上述計劃，並聲明他/她能游最少50公尺及其身體並無任疾病，令其不宜參加上述計劃。如果申請人因他/她的疏忽或健康或體能欠佳，而引致於參加這計劃的活動時傷亡，康樂及文化事務署則無須負責。
*家長/監護人或”授權人” 簽署:	                       	姓名:	                        	
*請將不適者刪去
               	日期:	                                            	
＃家長/監護人或經其家長/監護人授權者必須為十八歲或以上人士
(2) Declaration (All applicants must fill in this part)
(A) Applicants aged 18 or above should complete this declaration
1. I declare that I can swim for at least 50 meters and do not suffer from any illness that renders me unfit for the activities of the above scheme.  The Leisure and Cultural Services Department should not liable for any injury or death which I may suffer in the activities of the scheme, if the cause of injury or death is due to my own negligence or inadequacy in health and fitness:  
Signature Applicant: ______________________________________  Date: _____________________________
(B) For applicants aged under18, the following declaration should be completed by their #parents/ guardians or by persons authorized by their parents/guardian
2. I agree to allow ________________(applicant’s name) to participate in the above scheme and declared that he/she can swim for at least 50 meters and does not suffer from any illness that renders him /her unfit for the activities of the above scheme.  The Leisure and Cultural Services Department should not liable for any injury or death which the applicant may suffer in the activities of the scheme, if the cause of injury or death is due to his/her negligence or inadequacy in health and fitness:  
*Signature of parent/guardian or authorized person: _______________________ Name in Full: ______________________ Date:_______________________
*Delete where appropriate         ＃Parent/Guardian or authorized person should be at 18 years of age or above.
  LCS 68  (2008年3月修訂Revised on Mar., 2008)