汉语桥夏令营学生学生申请表 Application Form for 2011 Chinese Bridge Summer Camp July 15 July 16 July 17 26 July 27 July 28 30 July 31 Depart Washington Dulles Airport Arrive Beijing, transfer to domestic flight to Shaanxi or Jilin province Classes, cultural activities and site visits in assigned province Flight to Beijing Sightseeing, cultural programs and closing ceremony in Beijing Depart Beijing for Washington Dulles Airport Student pays * international airfare to/from Beijing *China visa fee * international medical and evacuation insurance *personal expenses * non-refundable application fee of $150. Please provide information about yourself below in English. Please print. 1. 申请人情况 / Personal Information 姓 /Last Name: 照片 Photo 名 /Given Name: 性别 /Gender: 出生日期 /Date of birth: 护照名 /Name as Listed in Passport: 国籍 /Citizenship: 护照号码 /Passport #: 护照有效期 /Passport Expiration Date:
年级 /Grade: 学校 /School : 当前地址 /Home Address: City: State/Zip: 电话 /Home Phone: 邮箱 /Student Email (print clearly): 2. 紧急联络人信息 / Emergency Contact Information 联络人 1/Contact #1 姓名 /Name: 家庭电话 /Home Phone: 办公电话 /Office Phone: 手机 /Cell Phone: 邮箱 /Parent #1 Email (print clearly): 联络人 2/Contact #2 姓名 /Name: 家庭电话 /Home Phone: 办公电话 /Office Phone: 手机 /Cell Phone: 邮箱 /Parent #2 Email (print clearly): 3. 汉语水平 / Chinese Language Proficiency 第一语言 /First Language: 第二语言 /Second Language:
家庭成员华文背景 /Chinese Background of Family Members: 是否来过中国? / Have you been to China before? 如果是, 上次在中国多长时间? / If yes, how long did you stay in China last time? 是否学过中文?/ Have you taken Chinese classes before? 如果是, 学习中文多长时间?/ If yes, how long have you been learning Chinese? 中文水平 / Chinese Language Proficiency (basic, intermediate, advanced): 4. 医疗信息 / Medical Information 1) 你目前是否在接受治疗?/ Are you currently receiving medical treatment? 如果是, 请解释 / If yes, please explain 2) 你目前是否在接受心理咨询或治疗?/ Are you currently receiving counseling or medication for any psychological or emotional conditions? 如果是, 请解释 / If yes, please explain
3) 你是否有任何过敏?/ Do you have any allergies? 如果是, 请解释 / If yes, please explain 5. 请陈述申请参加夏令营的原因 / Please state why you would like to participate in the Summer Camp. ( 请附详细说明, 最多 250 字 )(Use a separate sheet of paper; maximum 250 words.) 6. 请附上贵校教师推荐信一封并提供推荐人信息 / Please attach a letter of reference from one teacher at your school. 姓名 /Teacher Name 职务 /Teacher Title 联系电话或邮箱 /Phone or Email 7. 申请人声明 / Declaration of Applicant 我特此证明本表所填写的内容和提供的材料真实无误 I hereby certify that all the information on this form is true and correct. 申请人签字 /Signature of Applicant : 日期 /Date:
8. 父母签名 / Parent signature By signing this form you also agree, for yourself, your heirs and assigns, to release and hold harmless the Commonwealth of Virginia, George Mason University, its employees and agents, from any legal claim or liability for any bodily injury and personal property damage that is caused to you by the negligent act or omission of third parties while you are participating in the program. Students will pay their international airfare to/from Beijing, China visa fee, international medical and evacuation insurance, personal expenses, and the Chinese Bridge program non-refundable application fee of $150. Confucius Institute in China/Hanban will make all arrangements and pay for all group expenses in China. Confucius Institute at Mason will facilitate processing applications, provide a pre-departure orientation session, and pay for chaperones to accompany the group. Parent Signature: Date: Enclosed is my check made payable to George Mason University for $150.00 for the application fee. Application Deadline: Friday, April 22, 2011 Return your completed application to: Confucius Institute at Mason 4400 University Drive, MS 6D9 Fairfax, VA 22030 Tel: 703-993-7780 Fax: 703-993-7011 Email: cimason@gmu.edu Web: http://confucius.gmu.edu You may also send an advance copy of the application by email or fax.