2019汉语桥—美国高中生夏令营-ClevelandStateUniversity.PDF

2019 “汉语桥—美国高中生夏令营”教师申请表 Application Form for 2019 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 ： 照片 护照名/Passport Name: ___________________________ Photo 姓/Last Name: __________________________________ 名/Given Name: _________________________________ 出生日期/Date of birth: ___________________________ 国籍/Nationality: ___________ 性别/Gender: 男/Male 女/Female 护照号码/Passport #: 护照有效期/Passport Expiration Date: 职务/Position: 单位/Institution: _____________________ 工作地址/Work Address: _______________________________ 办公电话/Office Phone: 传真/Fax: 办公邮件Work Email: _________________________________ 使用语言情况/Which language(s) you can speak? 英语/English 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