Application Form for Chinese Bridge Summer Camp Students

/ Please provide information about yourself

below in English. Please print.
1. /Personal information
/Passport Name: __________________________________

Photo

/Last Name: _________________________________________

/Given Name: _________________________________________
/Gender: ______________ /Date of birth: _________________
/Nationality: _______________________ /Passport #: ____________________
/Passport Expiration Date: _____________________________________________
/Grade: _______

/School : ______________________________________________

/First Language:____________________________________________________
/Second Language:___________________________________________________
/Chinese Background of Family Members:______________________
____________________________________________________________________________
/Current Address: (including zip code)
_______________________________________________________________________________

/Phone: ______________________________

/Fax: ____________________________

/Cell: ________________________________

/Email: _________________________

2.
1/Contact #1
/Name: ________________________ /Home Phone: _____________________

/Office Phone: ___________________ /Cell Phone: _____________________

2/Contact #2
/Name: ________________________ /Home Phone: _____________________
/Office Phone: ___________________ /Cell Phone: _____________________
3. /Chinese Language Proficiency:
/Do you learn Chinese already?

/Yes

/No

/ If yes, how long have you been learning Chinese?

__________________________________________________________________
/Chinese Language Proficiency (Basic, Intermediate, Advance):
__________________________________________________________________
?/Have you been to China before?

/Yes

/No

?/If yes, how long did you stay in China last time?
__________________________________________________________________
4. /Medical Information
1) /Are you currently receiving medical treatment?
/Yes

/No

/If yes, please explain__________________________________

__________________________________________________________________
2)/Are you currently receiving counseling or medication
for any psychological or emotional conditions?
/Yes

/No

/If yes, please explain__________________________________

__________________________________________________________________
3)/Do you have any allergies?
/Yes

/No

/If yes, please explain__________________________________

__________________________________________________________________
5.
250 /Please state the reasons why
you would like to participate in the Summer Camp (Please attach a separate sheet, maximum 250
words).
6. /Please attach a letter of reference for your
application by one teacher from your school. List the referee information below:
/Name
_______________

/Phone or Email

/Title

_________________________

__________________

7. /Declaration of applicant:
:/ I hereby certify that:
/ All the information on this form is true and correct.

/Signature of Applicant:___________________________________

/Date____________