汉 语 桥 -美 国 高 中 生 夏 令 营 学 生 申 请 表
Application for Chinese Bridge Summer
Camp for American High School Students
请用英文回答下面的问题（电脑打印或用正楷填写）/
English. Please print.
Please provide information about yourself below in
1. 申请人情况/Personal information：
姓名/Name:
照片
___________________________
出生日期/Date
Photo
2”
of birth: __________________
国籍/Nationality: _______________________
性别/Gender: 男/Male
护照号码/Passport
#: ______________________________
护照有效期/Passport
第一语言/First
女/Female
Expiration Date: _________________
Language:___________________________
第二语言/Second
Language:_________________________
家庭成员华文背景/Chinese
Background of Family Members:____________________________
____________________________________________________________________________
2. 学校信息/School information
学校名称/School
Name: ___________________________________
学校地址/School
Address: (including zip code)
年级/Grade:
__________
____________________________________________________________________________
3. 紧急联络人信息/Emergency Contact
姓名/Name:
________________________与你的关系／Relationship:_____________________
电话：办公/Office:
姓名/Name:
______________手机/Cell: _______________家庭/Home: _______________
________________________与你的关系／Relationship:_____________________
电话：办公/Office:
______________手机/Cell: _______________家庭/Home: _______________
4. 汉语水平/Chinese Language Proficiency:
是否学过中文？/Have
you ever taken or are you taking Chinese lessons? 是/Yes
如果是，学习中文多长时间？/
否/No
If yes, how long have you been learning Chinese?
____________________________________________________________________________
中文水平/Chinese
Language Proficiency (Basic, Intermediate, Advance):
____________________________________________________________________________
是否来过中国?/Have
you been to China before? 是/Yes
如果是，上次在中国多长时间?/If
否/No
yes, how long did you stay in China last time?
____________________________________________________________________________
5. 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，请解释/If
yes, please explain_______________________________________________
____________________________________________________________________________
1) 你目前是否在吃药？/Are you currently taking any medicine?
是/Yes
否/No
如果是，请解释/If
yes, what is the medicine?_________________________________________
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，请解释/If
yes, please explain_______________________________________________
____________________________________________________________________________
3)你是否有任何过敏？/Do you have any allergies?
是/Yes
否/No
如果是，请解释/If
yes, please explain_________________________________________________
______________________________________________________________________________
6. 请陈述申请参加夏令营的原因。
（请附详细说明，最多 250 字）/Please state the reasons why you would
like to participate in the Summer Camp (Please attach a separate sheet, maximum 250 words).
7. 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 for your application
by one teacher from your school. List the referee information below:
姓名/Name
联系电话及邮箱/Phone
_______________
and Email
____________________________
职务/Title
__________________
8. 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/
form is true and correct.
I hereby certify that all the information on this
申请人签字/Signature of Applicant:___________________________________
日期/Date：____________
Application check list:
o Application Form
o School Transcript
o Teacher Recommendation
o Application Fee $150
Please send the application form along with the required documents to:
Confucius Institute
P.O. Box 114
106 Peck Hall
Middle Tennessee State University
Murfreesboro, TN 37132
Confucius Institute at Middle Tennessee State University
Waiver of Liability and Hold Harmless Agreement
Program: _______________________________________Fall/Spring/Summer 20____
I, the undersigned minor and parent/guardian, hereby voluntarily expressly and affirmatively execute this
agreement in return for permission for ______________________________ (participant) to participate in the program
activities. We recognize that there are many risks of injury, including serious disabling injuries, that may arise due to
participation in this activity and that it is not possible to specifically list each and every individual risk. However,
knowing the material risks and appreciating other injuries and even death are a possibility, we hereby voluntarily and
expressly assume all of the delineated risks of injury, all other possible risk of injury, and even risk of death, which could
occur by reason of participation.
If my child, _______________________, born ________, 19___, becomes ill or involved in an accident and I or
another adult whom I have authorized in writing to act in my absence cannot be contacted immediately (whether due to
unavailability or the need for immediate action under the circumstances), I authorize Middle Tennessee State University
to seek any necessary treatment and authorize the treating hospital/physician to provide my child any emergency medical
treatment they deem necessary or appropriate (including anesthesia). I accept full responsibility for any expenses incurred
in the medical treatment of my child, to the extent such expenses are not covered by the following:
Health Insurance Provider: ___________________Policy number: ______________Medicaid number: _____________
Child’s known allergies or physical conditions:
_________________________________________________________________________________________________
We hereby RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE Middle Tennessee State University, the Board of Regents of the State of Tennessee, their officers, or employees (hereinafter referred to as RELEASEES) from any and all liability, claims, demands, actions and damage or injury, including death, that may be sustained by me, or which may result from emergency medical treatment sought as a result of said participation in the activity. We further hereby AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or cost, including medical bills, court costs and attorney’s fees, that may occur due to participation in said activity, WHETHER CUASE BY NEGLIGENCE OF RELEASEES or otherwise. We subjectively understand the risks of participation in this activity. Knowing and appreciating these risks, I, the aforementioned participant’s parent/guardian, further state that I am fully competent to sign this agreement. We expressly intend for myself, for the participant, and for participant’s family, estate, heirs, administrators, personal representative, or assigns to be bound by this document, and it shall be deemed as a RELEASE, WAIVER, and DISCHARGE AND COVENANT NOT TO SUE the above-­‐named RELEASEES. This document shall remain in effect for each and every time participant participates in the activities listed herein. This release shall be construed in accordance with the laws of the state of Tennessee. We have had an opportunity to ask questions and any questions asked have been satisfactorily answered. (choose one) Parent ____
or
Guardian ____
___________________________________
Parent/Guardian of Participating Minor
_________________________________
Signature
Date ___________
Primary Phone _________________Alternate Phone __________________Email ___________________________
___________________________________
Minor Participant
_____________________________________
Emergency Contact (other than parent/guardian)
________________________________
Signature
__________________________
Primary Phone
Date ___________
_________________________
Alternate Phone