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Personal Data
*
Name (Chinese)
Male
Female
Other
*
Name (English)
*
ID Card/Passport Number
*
Birthday
*
Services received/schools attended
*
Current services received
*
Current service providers/schools
*
Mail address
*
E-mail
*
Phone number
*
Fax
*
Intellectual level
Normal
Sluggish
Mild
Moderate
Serious
*
Disability category
Down syndrome
Autism
Intellectual disability
Hyperactivity disorder
Physical disability
Visual impairment
Hearing impairment
Learning delays
Other
Family Situation
Parents' information
*
Father' s name
*
Age
*
Occupation
*
Phone number
*
Are you currently living with a member?
Yes
No
*
What is the relationship with members?
Good
Ordinary
Bad
*
Mother' s name
*
Age
*
Occupation
*
Phone number
*
Are you currently living with a member?
Yes
No
*
What is the relationship with members?
Good
Ordinary
Bad
Brother and Sister Information
Brother and sister 1
Name
Age
Occupation
Phone number
Are you currently living with a member?
Yes
No
What is the relationship with members?
Good
Ordinary
Bad
Brother and sister 2
Name
Age
Occupation
Phone number
Are you currently living with a member?
Yes
No
What is the relationship with members?
Good
Ordinary
Bad
Other Cohabiting Relatives and Friends
Name
Relationship
What is the relationship with members?
Good
Ordinary
Bad
Emergency Contact
*
Name
*
Relationship
*
Emergency contact phone number
(If the emergency contact person is not a parent, please fill in this column)
Download Form
Personal Data
*
Name (Chinese)
Male
Female
Other
*
Name (English)
*
ID Card/Passport Number
*
Birthday
*
Services received/schools attended
*
Current services received
*
Current service providers/schools
*
Mail address
*
E-mail
*
Phone number
*
Fax
*
Intellectual level
Normal
Sluggish
Mild
Moderate
Serious
*
Disability category
Down syndrome
Autism
Intellectual disability
Hyperactivity disorder
Physical disability
Visual impairment
Hearing impairment
Learning delays
Other
Family Situation
Parents' information
*
Father' s name
*
Age
*
Occupation
*
Phone number
*
Are you currently living with a member?
Yes
No
*
What is the relationship with members?
Good
Ordinary
Bad
*
Mother' s name
*
Age
*
Occupation
*
Phone number
*
Are you currently living with a member?
Yes
No
*
What is the relationship with members?
Good
Ordinary
Bad
Brother and Sister Information
Brother and sister 1
Name
Age
Occupation
Phone number
Are you currently living with a member?
Yes
No
What is the relationship with members?
Good
Ordinary
Bad
Brother and sister 2
Name
Age
Occupation
Phone number
Are you currently living with a member?
Yes
No
What is the relationship with members?
Good
Ordinary
Bad
Brother and sister 3
Name
Age
Occupation
Phone number
Are you currently living with a member?
Yes
No
What is the relationship with members?
Good
Ordinary
Bad
Other Cohabiting Relatives and Friends
Living with relatives and friends1
Name
Relationship
What is the relationship with members?
Good
Ordinary
Bad
Living with relatives and friends1
Name
Relationship
What is the relationship with members?
Good
Ordinary
Bad
Emergency Contact
*
Name
*
Relationship
*
Emergency contact phone number
(If the emergency contact person is not a parent, please fill in this column)
Download Form
