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
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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?
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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.
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Signature of applicant Date (dd/m