Application Form – Chinese Language Training Program

Tai Hu Center “Learning & Teaching” Program

Application Form

 

 

 

Program you’d like to enroll for

 

☐ Fall program, 03 Nov 2013 ~ 07 Dec 2013

☐ Spring program, 09 Mar 2014 ~ 29 Mar 2014

 

 

1. Personal information

Full Name : _________________________________        Gender:          ☐ Male          ☐ Female

Date of birth: ______(dd)_______(m)__________(y)       Nationality: __________________________

Passport No: ________________________________        Passport Expiration Date: _______________

First language: ______________________________        Second language: _____________________

Home Add: _________________________________         Contact No: __________________________

Email Add: _________________________________          Fax No: _____________________________

Religion: ___________________________________

 

2. Education and experience

Graduated from: ____________________________         Year of graduation: ____________________

Current job / position: _______________________________________________since______________

Previous job / position: _________________________________from_____________to_____________

 

3. Travel experience

Have you visited China before?    ☐No               ☐Yes              ☐Yes, more than once

Your purpose to China was?                      ☐Tour                        ☐Business   ☐Other, explain

How long did you stayed for?                    ☐1 week       ☐2 weeks     ☐A month or above

Which city (cities) were you in?    ______________________________________________________

 

4. Chinese language proficiency

Have you learned Chinese before?                                  ☐Yes              ☐No

If yes, how long have you been learning Chinese for? ________________________________________

How would you rate your Chinese language proficiency?       ☐Basic     ☐Intermediate     ☐Advanced

Have attended any Chinese culture related seminar before?           ☐Yes              ☐No.

If yes, please explain ________________________________________________________________

Have you read any of Master Nan Huai-Chin’s books before?           ☐Yes              ☐No

If yes, please list of the book you read __________________________________________________

 

5. Medical information

Are you currently receiving medical treatment?                                    ☐Yes              ☐No

If yes, please explain __________________________________________________________________

Are you currently receiving medication or counseling section for any psychological conditions?

☐Yes              ☐No          If yes, please explain _____________________________________________

Is there is any kind of activities that you cannot participate?           ☐Yes              ☐No

If yes, please explain __________________________________________________________________

Do you have any allergies? (food, skin, medication etc)                     ☐Yes              ☐No

If yes, please explain __________________________________________________________________

Do you have any kind of heart disease?                                     ☐Yes              ☐No

If yes, please explain __________________________________________________________________

Do you have asthma or breathing problem?                                          ☐Yes              ☐No

If yes, please explain __________________________________________________________________

Are you a smoker                 ☐Yes                          ☐No

Are you a drinker                 ☐Yes              ☐No

Is there any other health/ medical condition that we need to know about? ______________________

 

WTIS expects all program’s participants are in good health condition, and reserve the right t cancel one’s participation if untruth medical statement has bee found, whether it’s before program starts, or during campus.

 

6. Emergency contact

Full Name: _________________________________                     Home phone: __________________

Office phone: _______________________________                     Cell phone: ____________________

Relationship to applicant: _____________________                 Email add: _____________________

 

7. Teaching aspect

Do you have any teaching or training experience?                   ☐Yes              ☐No

If yes, please list out the subjects you’ve taught, and the age group of your students

____________________________________________________________________________________

______________________________________________________________________

I would like to teach                       ☐English                   ☐Art                           ☐Science

☐Baking/cooking  ☐Ceramic         ☐Woodwork

☐Sport     __________________________________

☐Others    __________________________________

 

8. Other

How did you learn about the program? ____________________________________________________

Why would you like to attend the program?

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

What is you expectation from the program? (What would you like to gain from it)

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

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Is there any dietary concern that we need to know about due to religious reasons? ___________________________________________________________________________________

Have you ever been charged, arrested or convicted of any offense or crime?         ☐Yes              ☐No

If yes, please explain __________________________________________________________________

 

 

 

I hereby certify that all information on this form is true, complete and correct. If false information is provided, WTIS reserves the right to cancel my participating before or during the program, and there will be no refund required.

 

 

____________________________________                                    _________________________

Signature of applicant                                                                    Date (dd/m