Application for JC Support for Young People with Diabetes 賽馬會年輕糖尿支援計劃網上申請

JC Support for Young People with Diabetes
賽馬會年輕糖尿支援計劃

Online application 網上申請

Good diabetes management requires self-monitoring of blood glucose multiple times a day. Before Continuous Glucose Monitor (CGM), regular finger-prick test was the only way to monitor glucose level. To help ease the pain and improve life with diabetes, and thanks to the sponsorship of the Jockey Club Charities Trust, Youth Diabetes Action will provide free CGMs for 2 years to selected children and youth with diabetes aged 2 to 30.
良好的糖尿病管理依靠每日多次的血糖測試，在連續血糖監測儀（CGM）面世前，患者只能使用手指刺針方式（俗稱「篤手指」）量度血糖。感謝賽馬會慈善信託基金的資助, 兒童糖尿協會將為2至30歲糖尿病患者提供兩年用量的CGM，讓他們得到全天候血糖監察，提高生活質素。

Download application 下載申請表格

Part I - Particulars of applicant 第一部份 - 申請人資料

Name (Eng) 英文姓名
Name (Eng) 英文姓名
Surname 姓氏
First name 名字
Name (Chi) 中文姓名
Name (Chi) 中文姓名
Surname 姓氏
First name 名字
Gender 性別
Type of Diabetes 糖尿病類型
Year & month of Diagnosis 確診年份及月份
Year & month of Diagnosis 確診年份及月份
Month 月份
Year 年份
Brand & model of Mobile Phone 智能電話牌子及型號
Brand & model of Mobile Phone 智能電話牌子及型號
Brand 牌子
Model 型號
Please select the type(s) of allowance received (if any) 請選取已獲取的援助／津貼（如有）

Part II - Details of parents or emergency contact 第二部份 - 家長或緊急聯絡資料

Name of first contact 第一位聯絡人姓名
Name of first contact 第一位聯絡人姓名
Surname 姓氏
First name 名字
Name of second contact 第二位聯絡人姓名
Name of second contact 第二位聯絡人姓名
Surname 姓氏
First name 名字

Part III - Current CGM Consumption 第三部份 - CGM使用現況

  • YDA reserves the right to allocate the brand and quantity of CGM to successful applicants. Applicants cannot arbitrarily request to change the approved CGM model, unless the applicant has reasonable grounds and obtains a referral form signed by a healthcare professional.
    YDA 保留分配CGM的數量、品牌及型號的決定權。申請人不能任意要求更換獲批之CGM品牌及型號，除非申請人有合理理由並取得由醫護人員簽發之轉介表
  • The quantity of CGM distributed under the Jockey Club Support for Young People with Diabetes’ programme is complementary to match the CGM programme of the Hospital Authority
    賽馬會年輕糖尿支援計劃派發的CGM數量將配合醫院管理局CGM計劃
Have you used CGM before? 曾否使用CGM？
Are you a pump user? 你是否胰島素泵使用者？
Brand of CGM currently using 現使用之CGM品牌
Are you currently getting CGM from Hospital Authority? 你現在是否從醫院管理局獲得CGM？
Brand and model of real-time CGM applied for 欲申請之實時CGM品牌及型號

Part IV - Supplementary Information 第四部份 - 補充資料

Are you planning to study or stay abroad for longer than 3 months during project period? 是否打算在計劃期內留學或逗留海外超過3個月？
e.g. Pregnancy, Special medical needs, relatively higher HbA1c, financial difficulty or other information 如懷孕、特殊醫療需要、糖化血色素偏高、經濟困難或其他補充事項

Notes 附註

  1. CGM supply will be on a first-come-first-served basis. 名額有限，先到先得，額滿即止。
  2. YDA reserves the right to amend the terms or cancel this Programme at its discretion without any notice. 本會有權更改或取消本計劃而毋須作出任何通知及解釋
  3. If an excess supply of CGM sensors is given due to miscalculation, applicants are liable to return any excess quantity to YDA. 倘若因計算錯誤而導致申請人獲多發放物資，申請人必須把物資退還
  4. All CGM distributed by YDA are not to be used for commercial or resale purposes. 所有兒童糖尿協會派發的連續血糖監測儀均不可用作商業或轉售用途。
  5. Selected users must consult their own attending medical professionals regarding CGM data or alerts. YDA will not be responsible for any medical data or alerts by CGMs provided to users. 獲選申請人需自行向主診醫護查詢任何與連續血糖監測儀有關的數據或警示。兒童糖尿協會恕不為所提供的連續血糖監測儀的任何醫學數據或警示負責。
  6. Allergy or bleeding may occur on the applied site of CGM, users must assume the risks themselves. 使用連續血糖監測儀之位置有機會出現敏感或流血等情況，用家需自行承擔風險。
  7. The information collected in the Jockey Club Support for Young People with Diabetes Programme is only used for programme application, approval, research and programme related purposes. At the end of the programme, the above-mentioned information will be destroyed. 賽馬會年輕糖尿支援計劃中收集的資訊僅作計劃申請、審批、研究及其他相關之計劃用途。計劃完結時，上述有關資料將被銷毀。

Consent Form 計劃同意書

I understand and agree myself / my child to participate in this programme, and agree to the following terms of the Jockey Club Support for Young People with Diabetes Project:
我明白和同意下列賽馬會年輕糖尿支援計劃的條款，並同意本人／本人子女參加該計劃：

  1. Allergy or bleeding may occur on the applied site of CGM
    明白使用連續血糖監測儀之位置有機會出現敏感或流血等情況
  2. I shall make good use of the given CGMs, otherwise I shall return the remaining unused CGMs to the Youth Diabetes Action.
    同意善用獲贈之連續血糖監測儀，否則會把餘下數量交還到兒童糖尿協會
  3. I agree that all CGM distributed by YDA are not to be used for commercial or resale purposes.
    同意所有兒童糖尿協會派發的連續血糖監測儀均不可用作商業或轉售用途
  4. I understand and agree to participate in surveys conducted by the Faculty of Medicine, The Chinese University of Hong Kong, for evaluating the benefits of the CGM
    參與香港中文大學醫學院所主導的連續血糖監測儀效益評估調查
  5. For the evaluation of the benefits of the usage of CGM, I agree that staff of YDA and delegated members of the study team of the Faculty of Medicine, The Chinese University of Hong Kong can access my/ my child’s CGM glucose data and relevant medical information for purposes of evaluating the effectiveness of CGM
    授權兒童糖尿協會職員及香港中文大學醫學院糖尿病研究人員，取得本人或本人子女的連續血糖監測儀的血糖數據及醫療資訊以評估使用連續血糖監測儀的效益
  6. Understand that Youth Diabetes Action is only responsible for the distribution of CGM. In case of technical issues with the CGM and other related tools or mobile applications, I will inquire with the manufacturer or supplier of the CGM
    明白兒童糖尿協會只為連續血糖監測儀的派發單位，如遇連續血糖監測儀及其他有關工具或智能電話應用程式的技術問題，將向連續血糖監測儀的生產商或供應商查詢
  7. Commitment of selected users
  • Learn and follow the instructions for proper use of CGM to improve diabetes management  學習使用連續血糖監測儀以改善管理糖尿病
  • Attend CGM installation and training sessions by YDA  出席YDA舉辦的連續血糖監測儀相關培訓課程
  • Attend HbA1c testing at YDA at the beginning, 6th, 12th and 24th month of the 2-year period of receipt of CGM, or submit proof from hospital  在計劃開始、計劃的第6、第12及第24個月到YDA進行糖化血紅素檢查，或提交醫院的報告