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20251203_JJKTM_晶晶幼稚園(屯門校)
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20251203_JJKTM_晶晶幼稚園(屯門校)
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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12月3日於晶晶幼稚園 屯門校，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 3 December 2025 at Jing Jing Kindergarten（Tuen Mun 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
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學童中文姓名 Child's Chinese Name (If any)
學童出生日期 Child's Date of Birth
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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
*
N-AM
K1-AM
K2-AM
K3-AM
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
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是 YES
否 NO
稱謂 Title
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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.
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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
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