Application Form
Nacel Short-Term Program Application Form
For Nacel use only: □Winter □Summer Year 20___ Coordinator/China: MAO Fuping Group Code __________________ State/Country _China_ Program Director______________ Dates ____________ Student # ________ □ESL □Tutorial □School □School/ESL
For Nacel China use only: 姓名 请申请人用中文填写 身份证号(如有)
______________
______________________
常用电话_______________
家庭地址______________________________________________ 电邮__________________ 学校名称______________________________________________ 年级/班级_______________ 请附户口本“申请人本人信息”复印件，个人护照之“含个人照片和信息”复印件一份， 如没护照，请马上办理。 如果是家庭居住，请附上你和父母微笑照片两张, 以及写给美国接待家庭的一封信 letter to your host family。
Please complete this application form in English (除部分要求用中文填写外，请本人用英语如实填写本申请表格)
First Name(名,拼音)_____________ Last Name(姓,拼音) ___________ Sex (性别) □M(男) □F(女) Birth date (出生日期) ____________(mm/dd/yy 月/日/年) Age (年龄)_____
American Name(英文名) ____________________ Nationality (国籍) _China_ Father’s Name(父亲姓名拼音) __________________Age(年龄) ______ Occupation(职务)___________ Mother’s Name(母亲姓名拼音) _________________Age(年龄) ______ Occupation(职务)____________ Father Work #(父亲单位电话)_86-______________Mother Work #(母亲单位电话) _86-______________ Parents (父母婚姻状况): □Married(已婚) □Separated(分居) □Divorced(离婚)
Home Address(家庭地址/英文)_________________________________________________________ If parents live at different addresses, indicate the address of the parent not living at home(如父母分居， 请列出其它地址) _______________________________________________________________ Home Telephone Number (家庭电话)_86-______________Email (请清楚填写) _______________________ Recommendation from Principal or English Teacher or Supervisor:(请校长或英语教师或班主任推荐) Academy(学习成绩): □Above average(优良) □average(中等) English(英语): □Above average(优良) □average(中等) Personality(性格): □Adaptable(适应能力强) □Introversion(内向) Behavior(行为): □Good (良好) □To be improved(有待提高) How long have you known the applicant(认识申请人多长时间)____________ Signature(签名): MP (手机):
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Application Form
STUDENT INFORMATION (II)
1） 2） Grades completed (几年级)___________Years of English learning (英语学习几年)?________. Do you have any type of special diet that we should know about for medical or religious reason? ___________ If yes, please explain (是否因健康或宗教原因有特殊饮食习惯? 3） 4) 5) 6) 7) 8) 9)
如有,请说明)_
__________________________________________________________________________ Do you have any serious pet allergies that would keep you from being able to live with pets? __ ___ If yes, please explain (是否对宠物过敏? What is your religious affiliation(宗教信仰)?
如有,请说明)?_
___________________________
_ ____________________________________
Will you attend church with your host family(是否愿意去教堂)? ________________________ My English is (我英语水平为) □Excellent (很好) □Good (较好)□Fair(中等) □Weak(较差) Do you require any special treatment while in the US? If yes, please explain (在美国是否有特殊
要求? 如有,请说明)?
__________________________________________________________
List any previous illnesses or injuries(是否有任何病史)? __ ____________________________ Will you accept a double placement?(你愿意和其他申请人共同居住在美国主人家庭吗？你仍有单独房间。 ) □Yes □No □Outgoing (友善) □Adaptable(适应能力强) □Introversion(内向) □Cheerful(爽快) □Flexible(随和) □Polite(礼貌) Describe Yourself (请描述一下自己) □Shy (害羞) □Positive(处事积极) □Cooperative(协作精神)
10) 11) 12)
Do you have brothers or sisters? If yes, please list their names and age (是否有兄弟姐妹？如有， 请
列出他们的姓名和年龄)
_________________________________________________________
List your favorite activities or hobbies (请写出你最喜欢的运动或爱好)_____________________ _________________________________________________________________________ Please indicate your reasons for wanting to participate in this program and your goals？(请说
明你参加这个项目的理由和目的)___________________________________________________
_________________________________________________________________________ 13) Why would you like to live with a host family and what will you contribute to the host family? (你为什么愿意居住在接待家庭？你能为接待家庭做些什么?) _____________________________________ __________________________________________________________________________ 14) What is your most and least favorite trait (请说明自己的最大的优点和缺点)? _______________________________________________________________________
15）Are you planning to take other programs(你计划参加其它项目吗) ? □High School /USA(美国高中大学连读)
□ Academic Year Program/USA(美国学年项目) □Europe or other Program(欧洲项目)
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Application Form
Nacel Short Term Program
PARENT STUDENT AGREEMENT 父母/孩子同意以下规定
1.) I understand the drinking and drug laws in the US and that if I break these laws, I could be sent home immediately? (我了解美国关于喝酒和吸毒的法律，如我违反这些法律，我将被立即送回国) □Yes □No I understand the importance of speaking only English while in the US? (我了解在美国只通过英 语进行交流的重要性) □Yes □No I agree to follow the rules of my host family and my program director? (我同意尊重美国接待家庭 和辅导员的建议) □Yes □No I understand that I may be placed in a host family who lives in the country as opposed to the city? (我理解我有可能住在美国郊区而非城市) □Yes □No I understand that I must pay for my own activities with the host family? (我理解我将为在接待家 庭我个人的开销另付费) □Yes □No I understand that I will not use my host family’s telephone without permission and I will always use a phone card when making phone calls that will incur any charges? (我理解不经过 主人同意，不得擅自使用电话，通常使用电话卡打电话) □Yes □No I understand that while in the host family home I should help with chores? (我理解我将适当协 助做家务) □Yes □No I understand that any disciplinary action necessary may be grounds for removal from the program? (我理解执行纪律是很重要的) □Yes □No I am aware of the law in the United States that smoking is not permissible for individuals under the age of 18 and I must not smoke while in the US? (我了解美国法律不允许 18 岁以下学生吸 烟，我保证在美国不吸烟) □Yes □No I certify that all of the answers given have been prepared by myself Release: In applying to be a member of the Nacel Open Door program, I confirm that I have read and understand the program rules and that I agree to be fully bound by them. If I break any of the rules, then I am subject to being sent home at my own expense with no refund of program charges. I agree to reimburse the host family, the study center, the school, and the program organizations for any damage that I may cause or any telephone charges that I incur. I authorize Nacel Open Door, the host family and the sending organization to take any medical action necessary, in the event of emergency, accident or illness. This may include but not be limited to placement in a hospital, use of a doctor for treatment and transportation to my home country, at my own expense. I understand that any expense incurred by me must be paid to the host family prior to my departure from the US. I will come to the US with a serious intention of studying the language. Student Signature（学生签字）_____________________ Date（日期） ___________________ Parent Signature（家长签字）______________________Date（日期） ___________________
2.) 3.) 4.) 5.) 6.)
7.) 8.) 9.)
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Application Form
IMMUNIZATION RECORD
免疫记录
To be completed by a licensed physician 请医生或学校医务人员填写 The applicant must have the following immunizations in order to be able to visit a school in the United States. Remember that some schools may have different immunization requirements which student must have before attending class and all immunizations are the student’s responsibility as they are not covered by medical insurance. 学生必须接种疫苗，否则无法入学。
Height（高） ______m Weight（重） _______kg Blood Pressure（血压） _________ Uncorrected vision（矫正前视力）R 右: _____ L 左: _____ With Correction（矫正后视力） R 右: ______ L 左: _____ Wearing contact lenses? （带隐形眼镜）□Yes □No Glasses? （眼镜）□Yes □No Hearing（听力） R 右: ________ L 左: ________ Any problem with the following systems? 以下系统是否有病， If yes, please explain.如有请说明 □ Cardiovascular system 心血管 □ Menstrual Cycle 月经周期 □ Respiratory System 呼吸系统 □ Ears, Nose Throat 耳鼻喉 □ Musculoskeletal 肌肉骨骼 □ Skin(acne etc.)皮肤（痔疮等） □ Eyes 眼 □ Metabolic/Endocrine 新陈代谢/内分泌系统 □ Teeth and Gums 牙 □ Gastrointestinal 肠胃系统 □ Neuropsychiatric 神经系统 □ Genito-Urinary System 泌尿系统 □ Pelvic 骨盆 □ Other 其它 Current health is 目前身体状况: □Excellent
Mo/Day/Yr 第一 次 月/日/ 年 很好
□Fair
一般
□Poor
较差 第四 次 月/日/ 年 第 次 五 月/日/ 年
第二 次 月/日/ 年
第三 次 月/日/ 年
Type of Vaccineo Polio 小儿麻痹 Diphtheria, Tetanus, Pertussis DTaP DTP 白喉/破伤风/百日咳 Or Tetanus and Diphtheria Td
或 破伤风和白喉
Pertussis 百日咳 Measles 麻疹 Mumps 腮腺炎 Rubella 风疹 Hepatitis B 乙肝 三次 Hepatitis A 甲肝 两次 Bacillus Calmette-Guerin卡介苗 TB Skin Test(Monovac)
TB皮下曼托测试
If no immunization, give date applicant had the disease of Pertussis, Measles, Mumps, or Rubella in the corresponding table
如没注射，请在相应栏目注明患病日期
说明
Results结果: □Positive阳性 □Negative 阴性 If TB Skin Test was Positive, List Date of Chest X-ray
如测试为阳性 请注明日期：
HIB Varicella (Chicken Pox)水痘 If no immunization, list year applicant had Chicken Pox如没注射，请注明生水痘日期
Physician’s Full Name 医生全名拼音___________________ Physician’s Signature 医生签字____________ Telephone Number 联系电话 ________________________ Date 日期_______________
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Application Form
Office of Asian Short-term Ed. Programs Deborah McDonough Decker M.Ed. Nat. Dir 2113 Terrace Dr. Copperas Cove TX 76522 800-874-7042 or 254-542-6736 Voice 254-542-6743 Fax
We, the student and parents of ___________________ （Student’s Name） authorize the release of any medical information from a medical institution or any entity holding medical information, to Nacel Open Door and/ or its agents for the purpose of initiating insurance claims. 我们作为学生家长在此同意，Nacel Open Door 或其指定机构可因保险理陪要求相关医疗机构 提供相关医疗信息。
Student Signature _________________________ Date _____________________ 学生签名（拼音） 日期 Parent Signature__________________________ Date ______________________ 家长签名（拼音） 日期
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