eHealth Consortium Limited


Systematic Training Programme and Certification for Healthcare and IT Practitioners ("STPC")


Enrolment Form ????

Form last updated on 28 June 2011.
???2011?6?28????


Please read the general notes before completing the Enrolment Form. Applicant must complete the enrolment form in BLOCK LETTERS
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Part A: Course Details ???? : ????

Please tick ??? the appropriate (please refer to the course leaflet for time and venue)
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Course Name
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Choice
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eHealth Awareness Course for eHealth Practitioners ????????
  • EA1a-2: 8 Jul @ 1830-2130 Fortress Hill


EA1a-2

eHealth Training for eHealth Executives ??????????
  • This course is completed ????????


 
Proficiency Training for eHealth Professionals ????????
  • EC1a: 18 Jul & 25 Jul @ 1800-2200 Kowloon Tong


EC1a

Proficiency Training for eHealth Professionals - Workshops ???????? - ?????
Priority will be given to enrolled participants of course EC1. EC1 ????????
  • To be announced. ?????


 
Part B: Personal Particulars ???? : ????
Title ?? (Dr, Mr, Mrs, Ms, Miss, others)*:
Surname in English (as appeared on HKID card)*:
Given Name in English (as appeared on HKID card)*:
???? (?????????????):
Correspondence Address ????:
Tel (Office) ?? (???):
Tel (Home) ?? (??):
Tel (Mobile) ????*:
Fax No ??:
Email ????*:
Name of Company ????*:
Name of Department ????*:
Position Held ??*:

Education Qualifications ????*:
Postgraduate or above ??????
University ??
Tertiary ??
Secondary ??

Healthcare and IT Professional ?????????*:
Doctor ??
Registered Nurse ???? #
Enrolled Nurse ???? #
IT Professional ??????
Others ?? (pls pecify ??? )
#Please email your practising certificate to register@ehealth.org.hk if you would like to claim the CNE points. ????CNE ??????????????? register@ehealth.org.hk?
Part C: eHealth Consortium Newsletter & Membership ???? : ?????????????
Yes, I wish to subscribe to the free eHealth Consortium's quarterly newsletter.
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Yes, I wish to subscribe to the membership for Individuals. (Subscription fee: HK$100 Waived in 2011.)
     ????????????2011 ??$100?????
About the eHealth Consortium Membership Scheme
The Membership Scheme and Subscription Fees are subject to annual reviews by the Council of eHealth Consortium.
The Consortium reserves the rights to amend the Membership Scheme. If there is any discrepancy between the Scheme's English and Chinese versions, the English version shall prevail.
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Part D: Payment Method ???? : ????
Registration Fee WAIVED. Please support eHealth Consortium activities by joining us as a member (see Part C).

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Notes
  1. Please send your completed enrolment form to the eHealth Consortium (eHC) by email, by fax or by post.
  2. The confirmation e-mail for acceptance or rejection will be issued 5 business days upon receipt of the application. Applicants who do not receive notifications in any form should contact eHC at 6992 2492
  3. Class Substitutions :
    • Once accepted to the enrolled course/class, participant cannot transfer to another course/class.
    • eHC reserves the right to make any necessary arrangements with regard to the class substitution.
  4. Personal data supplied in this enrollment form will be used only for purposes relating to enrolling the training courses and, if applicable, membership/newsletter subscription purposes.
  5. Applicants/Subscribers have the rights to request access to the personal data and to request correction of the personal data.
  6. If an applicant/subscriber requires access to and correction of the personal data, he/she shall submit a written request to eHC
  7. Seats are limited and enrolments will be processed on a first-come-first-served basis.
  8. eHC reserves the right to make necessary changes or cancel to classes.
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  2. ????????????????????????????????????????????6992 2492???????
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Applicant's Declaration ?????
I hereby declare that the information I provided in this application form is complete and correct. I have read the general notes above and agree to abide by the notes mentioned.

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(If you have any problem submitting your registration using this online form, please email register@ehealth.org.hk or call 6992-2492.)
(???????????????? register@ehealth.org.hk ??? 6992-2492?)

Form last updated on 28 June 2011.
???2011?6?28????