eHealth Consortium Limited


Systematic Training Programme and Certification for Healthcare and IT Practitioners ("STPC")


Enrolment Form 報名表格

Form last updated on 28 June 2011.
表格於2011年6月28日更新。

Please read the general notes before completing the Enrolment Form. Applicant must complete the enrolment form in BLOCK LETTERS
請在填表前注意表格的申請須知，並用正楷填寫表格。

Part A: Course Details 第一部份 : 課程資料

Please tick “√” the appropriate (please refer to the course leaflet for time and venue)
請選擇報讀課程並加上“√” (上課時間及地點請参閱章程)

Course Name
課程名稱		 Choice
選擇
eHealth Awareness Course for eHealth Practitioners 電子健康認知課程
  • EA1a-2: 8 Jul @ 1830-2130 Fortress Hill


EA1a-2

eHealth Training for eHealth Executives 電子健康行政人員課程
  • This course is completed 此課程已完滿結束


 
Proficiency Training for eHealth Professionals 電子健康技能培訓
  • EC1a: 18 Jul & 25 Jul @ 1800-2200 Kowloon Tong


EC1a
Proficiency Training for eHealth Professionals - Workshops 電子健康技能培訓 - 電腦工作坊
Priority will be given to enrolled participants of course EC1. EC1 課程參加者優先。
  • To be announced. 有待公布。


 
Part B: Personal Particulars 第二部份 : 個人資料
Title 稱謂 (Dr, Mr, Mrs, Ms, Miss, others)*:
Surname in English (as appeared on HKID card)*:
Given Name in English (as appeared on HKID card)*:
中文姓名 (須與香港身份證上資料相同。):
Correspondence Address 聯絡地址:
Tel (Office) 電話 (辦公室):
Tel (Home) 電話 (住宅):
Tel (Mobile) 流動電話*:
Fax No 傳真:
Email 電子郵箱*:
Name of Company 公司名稱*:
Name of Department 部門名稱*:
Position Held 職位*:

Education Qualifications 教育程度*:
Postgraduate or above 研究院或以上
University 大學
Tertiary 大專
Secondary 中學

Healthcare and IT Professional 醫護及資訊科技專業*:
Doctor 醫生
Registered Nurse 註冊護士 #
Enrolled Nurse 登記護士 #
IT Professional 資訊科技專業
Others 其他 (pls pecify 請註明 )
#Please email your practising certificate to register@ehealth.org.hk if you would like to claim the CNE points. 如欲申報CNE 學分，請電郵執業證明書之副本至 register@ehealth.org.hk。
Part C: eHealth Consortium Newsletter & Membership 第三部份 : 電子健康聯盟季刊及會員計劃
Yes, I wish to subscribe to the free eHealth Consortium's quarterly newsletter.
     本人希望收到電子健康聯盟通訊 （費用全免）
Yes, I wish to subscribe to the membership for Individuals. (Subscription fee: HK$100 Waived in 2011.)
     本人欲申請成為個人會員（2011 年度$100年費豁免）
About the eHealth Consortium Membership Scheme
The Membership Scheme and Subscription Fees are subject to annual reviews by the Council of eHealth Consortium.
The Consortium reserves the rights to amend the Membership Scheme. If there is any discrepancy between the Scheme's English and Chinese versions, the English version shall prevail.
關於電子健康聯盟會員計劃
會員計劃及會員費用由電子健康聯盟理事會釐定。
電子健康聯盟保留會員計劃內一切條款的任修改權及最終決定權。如計劃內的中、英文版本有任何差異或衝突之處，概以英文版本為準。
Part D: Payment Method 第四部份 : 付款方法
Registration Fee WAIVED. Please support eHealth Consortium activities by joining us as a member (see Part C).

費用全免。請支持電子健康聯盟活動，加入成為會員（見第三部份）


Notes
  1. Please send your completed enrolment form to the eHealth Consortium (eHC) by email, by fax or by post.
  2. The confirmation e-mail for acceptance or rejection will be issued 5 business days upon receipt of the application. Applicants who do not receive notifications in any form should contact eHC at 6992 2492
  3. Class Substitutions :
    • Once accepted to the enrolled course/class, participant cannot transfer to another course/class.
    • eHC reserves the right to make any necessary arrangements with regard to the class substitution.
  4. Personal data supplied in this enrollment form will be used only for purposes relating to enrolling the training courses and, if applicable, membership/newsletter subscription purposes.
  5. Applicants/Subscribers have the rights to request access to the personal data and to request correction of the personal data.
  6. If an applicant/subscriber requires access to and correction of the personal data, he/she shall submit a written request to eHC
  7. Seats are limited and enrolments will be processed on a first-come-first-served basis.
  8. eHC reserves the right to make necessary changes or cancel to classes.
申請須知
  1. 請將填妥的報名表格電郵、傳真或郵寄致電子健康聯盟。
  2. 申請者將於五個工作內收到電郵通知，確認或拒絕申請。申請人如在期間尚未收到任何通知，請致電6992 2492與本機構聯絡。
  3. 學額轉讓
    • 一經取錄，學員不得轉讀其他課程。
    • 本機構將保留有關學額轉讓事宜的一切權利。
  4. 本申請表上提供的個人資料，僅供作處理有關報讀課程及申請接收電子健康聯盟通訊或申請成為電子健康聯盟個人會員(如適用)事宜之用
  5. 申請人或訂戶有權要求查閱及更正其本身的個人資料。
  6. 如果申請人或訂戶需要查閱或更正其個人資料，其本人必須透過書面向電子健康聯盟提出。
  7. 由於名額有限，報名以先到先得方式進行。
  8. 本機構保留取消及重新安排課程之一切權利。
Applicant's Declaration 申請人聲明
I hereby declare that the information I provided in this application form is complete and correct. I have read the general notes above and agree to abide by the notes mentioned.

本人謹此聲明在此申請表格中所填報之資料均屬正確無訛。本人已閱讀『申請須知』，並完全同意及遵守有關事項。

(If you have any problem submitting your registration using this online form, please email register@ehealth.org.hk or call 6992-2492.)
(如對本申請表格有任何查詢，請電郵 register@ehealth.org.hk 或致電 6992-2492。)

Form last updated on 28 June 2011.
表格於2011年6月28日更新。