Cantonese Autism Family Circle 廣東話自閉症家庭群組 參加者姓名 Name of Participant * First Name Last Name 電子郵件 (以便接收群組相關的訊息) * Email (for group related information) 聯絡電話 * Phone Number (###) ### #### 孩子的姓名及年齡 * Child's name and age (###) ### #### 孩子與您的關係 * Relationship with child (###) ### #### 您的孩子是否有以下任何診斷或學習差異? （請勾選所有適用項目） Does your child have any of the following diagnoses or learning differences? (Please check all that apply) 自閉症 Autism 專注力不足/過度活躍症 ADHD 學習障礙 Learning Disability 其他 Other 如選擇其他, 請註明 (例如: 懷疑自閉症) If other, please specify: (For example: suspected Autism) 孩子的溝通模式:（請勾選所有適用項目） Child’s mode(s) of communication: (Please check all that apply) 身體語言 Body language 聲音 Sounds 單詞（例如：鞋子、狗狗、抱）Words (e.g. shoe, doggy, up) 由 2 至 4 個詞組成的短句 2-4 word phrases 長於 4 個詞的句子 Sentences longer than 4 words 敘述故事、進行對話 Stories, conversations 輔助及替代式溝通 Augmentative and Alternative Communication (AAC) 其他 Other 如選擇其他，請註明 If other, please specify 您是否現有 Speech Meta 的客戶? * Are you a Speech Meta Client? 是 Yes 否 No 您的孩子目前是否正在接受言語治療? Is your child currently receiving speech therapy? 是 Yes 否 No 您是透過甚麼途徑認識此群組?（請勾選所有適用項目） Where did you hear about this group? (Please check all that apply) 社交媒體 Social Media Speech Meta 網頁 Website 海報 Posters Speech Meta 治療師 Therapists 推薦人 Referral 其他 Others 如選擇其他或推薦人請註明 If other or referral, please specify: 哪幾個平日上午最適合您參加未來的聚會? (請勾選所有適用項目) * Which weekday morning(s) work best for you to join future meetings? (Please check all that apply) 星期一 Monday 星期二 Tuesday 星期四 Thursday 星期五 Friday 您是否有其他意見或查詢? Any comments or questions? 同意聲明 CONSENT 為方便通知參加者每月聚會的日期及報名資訊，Speech Meta 將建立一個只供公告用的 WhatsApp 群組。群組只會用於發放提醒及相關資訊。 To facilitate notifying participants about the dates and registration information for the monthly gatherings, Speech Meta will create a WhatsApp group for announcements only. The group will be used solely for sending reminders and related information. 我願意加入 WhatsApp 公告群組以接收提醒和資訊。I agree to join the WhatsApp announcement group for reminders and updates. 本人明白及同意：由於小組的 WhatsApp 公告群組需要以電話號碼加入，其他參加者將能看見我的電話號碼。此群組只作公告之用，僅由 Speech Meta 發放提醒及相關資訊，群組成員之間不能於群組內互相發訊息。I understand and agree: Since the WhatsApp announcement group requires phone numbers to join, other participants will be able to see my phone number. This group will be used for announcements only, managed by Speech Meta, and members will not be able to message each other within the group. Speech Meta 會透過電郵發放活動通知及最新消息。 Speech Meta will send event notifications and updates by email. 我希望接收有關 Speech Meta 活動的電郵及最新消息。I would like to receive event emails and updates from Speech Meta. Thank you!
