主頁 Home
關於我們 About VSEC
檢測項目 Program
兒童視力 Child Vision
義工招募 Be VSEC Volunteer
傳媒報導 Media
學校預約 BOOK NOW
20251119_JJKHSK_晶晶中英文幼稚園(洪水橋)
Home
20251119_JJKHSK_晶晶中英文幼稚園(洪水橋)
Please enable JavaScript in your browser to complete this form.
兒童視力檢測家長同意書
香港兒童視力篩查及教育中心將於2025年11月19日於晶晶中英文幼稚園 洪水橋校，為您的孩子提供免費的視力篩查。目的是及早發現兒童的視力問題，以便他們能夠在黃金時期糾正問題。 Hong Kong Vision Screening and Education Centre offers your child free vision screen on 19 November 2025 at Jing Jing Anglo Chinese Kindergarten (Hung Shui Kiu Branch). It aims to early identify visual problems of children so that they can rectify the problem at the golden age.
學童英文姓名 Child's English Name
*
First
Last
學童中文姓名 Child's Chinese Name (If any)
學童出生日期 Child's Date of Birth
*
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
/
MM
1
2
3
4
5
6
7
8
9
10
11
12
/
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
學童於預約視力檢查時必須年齡介乎二至六歲。
Children must be aged between 2 to 6 years on eye examination appointment day.
學童性別 Child's Gender
*
男性 Male
女性 Female
班別 Class
*
K1-AM
K2-AM
K3-AM
K1-PM
K2-PM
K3-PM
Next
家長同意書 Parent or Guardian Consent
本人同意學童參與本中心於學校內提供的視力驗測 Will your child participate in Visual Screening Program provided by VSEC at school
*
是 YES
否 NO
稱謂 Title
*
請選項
先生 Mr
小姐 Ms
女仕 Mrs
家長或監護人姓名 Parent/Guardian's Name
*
聯絡電話 Contact Number
*
Next
本人同意學童參加香港理工大學眼科視光學診所提供的兒童綜合眼科視光檢查計劃，並同意將個人資料及學童視力篩查報告轉介給香港理工大學。I hereby consent to allow the child named in this form to participate in Free Comprehensive Eye Examination for Children provided by Hong Kong Polytechnic University Optometry Clinic. I also agree to the referral of personal data and the vision screening report to The Hong Kong Polytechnic University.
*
同意 Agree
不同意 Not Agree
學童的年齡必須介乎二至六歲。
Children must be aged between 2 to 6 years.
學童須由家長或監護人帶到香港理工大學眼科視光學診所接受眼科檢查。
Children must be accompanied by a parent or guardian to the Hong Kong Polytechnic University Optometry Clinic for the eye examination.
在檢查過程中，眼科視光師會使用放瞳藥水，以確保能夠全面評估眼睛的健康狀況。
During the examination, optometrists will use eye drops to ensure a comprehensive assessment of eye health.
合資格學童將會由香港理工大學眼科視光學診所透過登記電話聯絡其家長。
Qualified children will be contacted by the Hong Kong Polytechnic University Optometry Clinic via registered contact phone number.
參加者如果預約後未能出席或遲到超過15分鐘，將會視為放棄此次檢查的安排。（在已預約的日期前一天或更早的情況下，最多可重新安排預約時間兩次）
Participants made an appointment but absent or register 15 minutes later than the appointment time, it will be considered a forfeiture of the arrangement for this examination. (Maximum 2 rescheduling one day or more before the appointment is allowed)
香港兒童視力篩查及教育中心保留最終決定權。
The Hong Kong Children's Vision Screening and Education Centre reserves the final decision.
在檢查過程中，眼科視光師會使用放瞳藥水。 During the examination, optometrists will use eye drops.
*
同意使用放瞳藥水 Agree to use eye drops
不同意使用放瞳藥水 Not Agree to use eye drops
了解更多有關放瞳藥水
Know more about the eye drops
您需要同意上述事項才能報名參加於香港理工大學眼科視光學診所的免費兒童全面眼科檢查計劃，但學童仍然可以報名參加於校內進行的視力篩查服務。
Agreement to the above terms is required to register for this free comprehensive eye examination program for children in Hong Kong Polytechnic University Optometry Clinic. However, the child can still register for the vision screening service conducted on campus.
本人同意學童於是次眼科健康檢查時，同時接受「利用智能手機作光學檢查」的研究計劃 I agree for the child to participate in the research project on " Smartphone-based photorefraction" during this eye health examination.
*
同意 Agree
不同意 Not Agree
了解更多「利用智能手機作光學檢查」詳情
"Smartphone-based photorefraction" Program Detail
回到上頁 Previous
Submit 遞交表格
