Chinese name  _____________________     English name ____________________________

Age：_________                               Current Grade：______________                                                           

Current School Name：_____________________    County: __________________

School Release Time: ______________    Language spoken at home: ____________   

Home Address ：__________________________________________ 

Home phone ：___________   Father’s Name: ___________   Mother’s Name: _________

Mom’s Cell: __________________；Dad’s Cell :____________________

Email Address:  ________________________________

Emergency Contact  : _____________________       Phone #：___________________

Health information that the school must know：____________________________________

Insurance Company：________________________

Parent/Guardian Signature：________________  Date of Application：__________