Social Outing Request 長者外出申請

Request for Same Day Social Outings 申請長者即日來回的社交外出

Please submit completed form to the floor nurse 24 hours prior to the requested outing date for arrangement. 請將填妥的表格在外出日期的 24 小時前交給樓層護士，以作安排。
Resident’s Name 長者的名字: *

First Name 名字 Last Name 姓氏
Resident’s Room Number 長者的房間號碼: *
Name of the Visitor: 訪客的名字: *

First Name 名字 Last Name 姓氏
My Email 我的電郵 : *
example@example.com
My phone number 我的電話:

Area Code Phone Number
Date of Outing: 外出日期:

Month Day Year
Date
Time of Outing: 外出時間:

Hour Minutes

AM/PM Option
Return Time: 返回時間:

Hour Minutes

AM/PM Option
Location of Outing & Activity外出時會去的地方及活動 :
I agree that I will follow the infection control guidelines and I have also obtained consent among my family members that I will take my loved one out for social outings. 本人同意我會遵守所要求的防疫措施，亦已取得長者其他家人的同意，安排長者外出。 *

Yes I agree 我同意
Signature of the Visitor 長者的訪客簽署

Clear
Should be Empty:

Request for Same Day Social Outings 申請長者即日來回的社交外出