申请人信息 Application Information 申请人详细信息 Applicant Information. 请列出申请人以前就读的学校, 以距今最近的就读学校开始 Please list the applicant s

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1 入学申请表 Application for Admission 中芯国际员工 SMIC Employee 非中芯国际员工 Non SMIC Employee 申请人基本信息 Applicant Information 姓名 ( 中文 )Chinese Name: 姓名 ( 英文 )Passport Name( Please Print): Last First 请在此粘贴彩照 Paste 4cm x 5cm Color Photo Here 性别 Gender: 男 M/ 女 F 国籍 Nationality: 出生日期 Birth date: / / 出生地 Place of Birth: 申请 Apply : 小班 CP2/ 中班 CK/ 大班 CK2 Month Day Year 小班 EP2/ 中班 EK/ 中文班中国户籍地址 Address for Chinese ID: 居住地址 Address in Shanghai: 邮编 Zip: 家长联系方式 Parent s 电话 Parent s phone: 家长联系方式 2Parent s 电话 Parent s phone: 申请表格经由本人亲自递交或电邮至 : 中国上海市浦东新区青桐路 9 弄 2 号邮编 : 2020 上海市民办中芯幼儿园招生办公室 KG_info@smicschool.com 招生办公室电话 : Submit application form via or in person to: Kindergarten Admission Office The SMIC Private Kindergarten No.2 Lane 9 Pudong New Area Shanghai 2020 PRC KG_info@smicschool.com Admission Office Tel:

2 申请人信息 Application Information 申请人详细信息 Applicant Information. 请列出申请人以前就读的学校, 以距今最近的就读学校开始 Please list the applicant s previous schools, beginning with the school most recently attended 入学日期 Dates attended 学校名称 School Name 年级 Grade 2. 请列出申请人在中芯学校或幼儿园就读的兄弟姐妹 Please list the applicant s siblings attending The SMIC Private School or Kindergarten 姓名 Name: 年级 Grade: 姓名 Name: 年级 Grade: 姓名 Name: 年级 Grade:. 申请人是否是独生子女 Applicant is the only child in your family 是 Y/ 不是 N 4. 如果申请人是中国国籍, 请填写以下户籍信息 If the applicant is Chinese, please write down the information below 户籍类型 : 常驻 / 蓝印 / 人才引进居住证 / 其他身份证号码户籍所在地街道户籍所在地居委籍贯邮编 5. 如果申请人是外籍, 请填写护照号码 If the applicant is a foreigner, please write down the Passport Number 护照号码 Passport Number: 2

3 联络信息 Contact Information 父母信息 Parent Information 姓名 ( 中文 )Chinese Name: 姓名 ( 英文 )Passport Name( Please Print): Last First 关系 Relationship to Applicant: 国籍 Nationality: 语言 Language: 单位名称 Employer: 部门和职务 Department and Job Title: 员工号码 ( 中芯员工必填 )Employee No.(Only for SMIC Employees): 父母信息 2 Parent Information 2 姓名 ( 中文 )Chinese Name: 姓名 ( 英文 )Passport Name( Please Print): Last First 关系 Relationship to Applicant: 国籍 Nationality: 语言 Language: 单位名称 Employer: 部门和职务 Department and Job Title: 员工号码 ( 中芯员工必填 )Employee No.(Only for SMIC Employees):

4 紧急联络信息与健康信息 Emergency Contact Information and Health Information 紧急联络信息 Emergency Contact Information 姓名 : 出生日期 : 性别 : Name: Birth Date: Gender: 紧急连络人 ( 若幼儿发生紧急事故, 园方将依您填写的联络人顺序联络, 请务必填写三位联系人信息 ) Please list persons to be contacted in case of an emergency (persons will be contacted in the order they are listed) 姓名 Name 关系 Relationship to Student 电话 Phone Number 语言 language 健康信息 Health Information. 平时健康情形 : 良好普通不佳血型 : General Health Status Good Average Poor Blood Type: 2. 需要让园方知道的健康相关状况健康问题或特殊疾病 Does your child have any health problems/conditions that the school should be aware of?. 长期服用之药物 Has your child been prescribed any long-term medications? 4. 过敏物 Allergies: 食物 Food 药物 Drugs 其它 Other 4

5 5. 请确认学生是否接受过这些疾病的治疗 Please check if student has received medical treatment for any of the following conditions: 列表 List Yes No 列表 List Yes No 列表 List Yes No 习惯性脱臼 Frequent Dislocation 高热惊厥 Fever Seizures 肺炎 Pneumonia 癫痫 Epilepsy 流行性腮腺炎 Mumps 红疹 Rash 猩红热 Scarlet Fever 扁桃腺炎 Tonsillitis 肺结核 Tuberculosis 晕眩 Dizziness 胸痛 Chest Pain 贫血 Anemia 中耳炎 Ear Infections 水痘 Chicken Pox 糖尿病 Diabetes 湿疹 Eczema 眼疾 Vision Problems 多动症 ADHD 习惯性感冒小儿麻痹 A 型肝炎 Frequent Colds Poliomyelitis Hepatitis A 气喘 Asthma 诵读困难 Dyslexia B 型肝炎 Hepatitis B 单细胞增多症 Mononucleosis 习惯性头痛 Frequent Headaches 听力障碍 Hearing Problems 肾上腺切除 Adenoidectomy 心脏病 Heart Problems 风湿热 Rheumatic Fever 6. 请确认学生是否完成下表所列疫苗 Please indicate if student has received immunizations for the following: 疫苗 Vaccination 结核疫苗 (TB) Tuberculosis Vaccine 乙肝疫苗 (HepB) Hepatitis B Vaccine 脊灰疫苗 (PV) Poliomyelitis Vaccine 白百破疫苗 (DPT) Diphtheria Pertussis Tetanus Vaccine 流脑疫苗 (MCV) Meningococcus Vaccine 注射日期 Date Given (yyyy/mm/dd) 5 疫苗 Vaccination 乙脑疫苗 (JEV) Japanese Encephalitis Vaccine 麻腮风 (MMR)Measles 2 Mumps Rubella Vaccine 2 甲肝疫苗 (HepA) Hepatitis A Vaccine 2 2 麻疹疫苗 (MV) Measles Vaccine 4 麻疹风疹 (MR) Measles Rubella Vaccine 2 水痘 (VZV) Varicella Zoster Vaccine 4 白破疫苗 (DT) Diphtheria Tetanus Vaccine 2 2 其他 Others 注射日期 Date Given (yyyy/mm/dd)

6 7. 若学生在园突发紧急情况时, 您是否同意由保健室将学生送至医院? I give permission for my child to be brought to the school s Health Office for treatment, then to a hospital if necessary. 愿意 Consent 不愿意 Do Not Consent 8. 若需转送医院时, 您希望园方将其送至哪家医院 ; 若无特别指定, 园方将送往浦东儿童医学中心 If your child requires immediate hospitalization, he/she will be sent to Pudong Children s Hospital. If you do not wish for your child to be sent to this hospital, please indicate your preferred hospitals below:. 2. 我同意, 依照上述情况, 中芯学校及幼儿园员工中芯保健中心医护人员可给予我的孩子急救帮助对于急救产生的任何后果, 上述人员将不负任何责任 ( 以上信息由班主任和医务人员掌握, 不对外公开 ) I hereby give consent for The SMIC Private School and Kindergarten s faculty and medical staff of the SMIC Clinic to administer first aid to my child in accordance to the terms detailed on this sheet. I will not hold the school and/or any of its representatives responsible for any liability resulting from administration of this first aid by these persons. (Information provided on this form will be kept confidential with homeroom teachers and school doctors only) 我承诺 : 以上提供的资料属实, 如有因虚假或隐瞒而造成任何后果, 其责任由本人自负 I understand that, if any information I have provided above is found to be inaccurate, I will be held responsible for any consequences. 监护人签名 Signature of Guardian 与学生关系 Relationship to Student 监护人证件号 ID Number of Guardian 日期 Date 6

7 申请材料清单 Application Checklist 材料列表 List 完整的申请表 Application Form 出生证明复印件 Copy of Birth Certificate 疫苗接种复印件 Copy of Vaccine Record 户籍首页及本人页复印件幼儿居住证复印件父亲 / 母亲居住证复印件父亲 / 母亲居住证积分副联复印件上海户籍 SH ID 非上海户籍 Non SH ID 港澳台 HK/MO/TW 外籍 Foreigner 护照复印件 Copy of Passport 居留许可证复印件 Copy of Resident Permit for foreigners in China * 永居身份证明复印件 Copy of Permanent Resident Permit from another country 注 : 标记 * 的表示如有该项材料则需提供复印件 *Stands for optional items 请提供申请人完整的申请材料, 只有当申请人的申请信息完整后入学申请才会被考虑学生录取前必须参加测评, 我园将有权决定申请者的被录取资格以及就读的班级申请材料将不予退还, 仅保留至次年的月 0 日 ( 请务必将表格中的信息填写完整 ) All materials must be received before applicant can be evaluated for admission. The SMIC Private Kindergarten reserves the right to deny admission to applicants who would not benefit from the educational program being offered. Eventual acceptance and /or class are decided by the administration of the SMIC Private Kindergarten. We will keep the application form until next school year November 0 th (Please be sure to fill all the fields, leave nothing blank). 我声明我是此文件的法定监护人我已经阅读并同意此文件所包含的所有条款和条件此申请表中所填信息和附加材料真实无误若有不实之处, 上海市民办中芯幼儿园将不予录取或退学 By signing below, I declare that I am a legal guardian of the applicant named on page one of this document. I have read and agree to all terms and conditions contained within this application form. All information contained in this application form and its accompanying application materials is complete and correct to the best of my knowledge. I understand that omission of relevant academic and/or behavioral information is grounds for rejection or suspension/expulsion. 家长签名 Parent s Signature: 日期 Date: 7

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申 请 人 信 息 Application Information 申 请 人 详 细 信 息 Applicant Information. 请 列 出 申 请 人 以 前 就 读 的 学 校, 以 距 今 最 近 的 就 读 学 校 开 始 Please list the applicant s

申请人信息 Application Information 申请人详细信息 Applicant Information. 请列出申请人以前就读的学校, 以距今最近的就读学校开始 Please list the applicant s