2015汉语桥—美国高中生夏令营教师申请表.doc

2015“汉语桥—美国高中生夏令营”教师申请表 Application orm for 2015 Chinese Bridge Summer Camp Chaperons 请用英文提供以下信息，并打印。/ Please provide following information and type in English. 1. 申请人情况/Personal information： /Passport Name: ___________________________ 姓/Last Name: __________________________________ 名/Given Name: _________________________________ 出生日期/Date of birth: ___________________________/Gender: 男/Male 女/Female 汉语/Chinese 其他/Other 如果你选择“其他”，请说明。/If you choose “other”, please indicate. _____________ 2. 紧急联络人信息 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: ___________________ 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: __________________ 3. 医疗信息/Medical Information 1) 你目前是否在接受治疗？/Are you currently receiving medical treatment? 是/Yes 否/No 如果是，请说明/If yes, please indicate. 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? 是/Yes 否/No 如果是，请说明/If yes, please indicate. 3) 你是否有任何过敏？/Do you have any allergies? 是/Yes 否/No 如果是，请说明/If yes, please indicate. 4. 项目背景/ Program Background 1) 是否到过中国?/ Have you been to China before? 是/Yes 否/No 2) 是否参加过“汉语桥-美国高中生夏令营”项目？哪年参加的？/ Have you participated in the “Chinese Bridge-Summer Camp for U.S. High School Students” before? 是/Yes （when: ） 否/No 5. 请附上个人简历/Please attach your CV (Please attach a separate sheet, minimum 150 words.) 申请人声明/Declaration of applicant: 我特此证明:/ I hereby certify that: 本表所填写的内容和提供的材料真实无误/ All the information on this form is true and correct 照片 Photo 申请人签字/Signature of Applicant_________________________ 日期/Date： _________________________