YONG-EN ACTIVE HUB YEAH! REFERRAL/APPLICATION FORM 永恩活跃社推介表与表格
A Programme by Yong-en Care Centre
PERSONAL DETAILS 个人资料
Name 姓名:
*
First Name
Last Name
Gender 性别
*
Male 男
Female 女
Last 3 numbers & alphabet of NRIC 身份证的最后三个号码与字母
*
Nationality 国籍
*
Singaporean 新加坡公民
Malaysian 马来西亚公民
Indonesian 印度尼西亚公民
Filipino 菲力宾公民
Vietnamese 越南公民
Others 其他
Birth Date 出生日期
*
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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18
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20
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23
24
25
26
27
28
29
30
31
Day
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a year
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
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1991
1990
1989
1988
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1986
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1982
1981
1980
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1963
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1950
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1948
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1945
1944
1943
1942
1941
1940
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1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Address 地址:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Contact No. 联络号码 (1)
*
Contact No. 联络号码 (2)
Email 电子邮件地址:
Marital Status 婚姻状况
*
Single 单身
Married 已婚
Widowed 守寡
Separated 分居
Divorced 离婚
Religion 信仰
*
Christianity 基督徒
Catholic 天主教
Muslim 回教徒
Buddhist 佛教徒
Taoist 道教
Hinduism 印度教
Other
Race 种族
*
Chinese 华族
Malay 马来族
Indian 印度族
Eurasian 欧亚族
Other
Spoken Language 口语
*
English 英语
Mandarin 华语
Malay 马来语
Tamil 印度语
Other
Dialects 方言
Cantonese 粤语
Hokkien 福建
Teochew 潮州
Hakka 客家
Other
Employment Status 就业状况
Retired 退休
Employed 受雇
Current Employment Position 目前的职务
Previous Employment Position 从前的职务
Mobility 行动状况
*
Independent 独立
Walking aid from Quad stick/frame 需借助手杖
Manual Wheelchair 手推轮椅
Motorised wheelchair 电动轮椅
Other
PROGRAMMES INTERESTS 感兴趣的节目
You may choose more than one 你可选择多个
GymTonic 健得力 - 体能训练
YEAH! Workshops and Activities 永恩活跃社!课程和活动
REFERRAL INFORMATION 推介资料
Source of Referral 推介来源
Self application 自我推介
Referral by Organisation (Please fill in the following infos) 机构推介(请填写以下)
Name of Referral 推介人姓名:
First Name
Last Name
Organisation of Referral 推介机构:
Contact of Referral 推介人联络号码:
Email of Referral 推介人电子邮件地址:
example@example.com
Reason(s) for Referral 推介原因
Maintain/Improve physical fitness 维持或改善身体素质
Maintain/Improve psycho-social wellness 维持或改善心理社交健康
Leisure and life enrichment 休闲和生活充实
Other
NEXT OF KIN INFORMATION 近亲资料
Next of Kin (NOK) available? 有近亲吗?
Yes 有
No 没有
*If yes, please provide details below. (For emergency contact.) 如有,请填一下表格(只用在紧急联络)
NOK Name 近亲姓名
First Name
Last Name
Relationship 关系
Contact no of NOK 近亲联络号码
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Submit Application 递交申请
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