Dr. Lang’s Chinese Bilingual School

郎艳霞双语学校幼儿夏令营

Pre-k Only - Chinese Summer Camp Application Form申请表

Registration fee: $______

选择营区Select the campus: ” Dunwoody Camp ” Johns Creek Camp

姓名：中文 ________________ 英文 ___________________________

Name: Chinese name English name

出生日：____________

DOB

所在学校/幼儿园：_______________ 家庭住址：_________________________

School/daycare attending Home address

住宅电话: _______________ E-mail: ______________________________________

Home phone #

父母手机: _____________________ 其他紧急情况联系电话：_____________________

Parent’s Cell Other emergency Contact Phone #

健康状况Health problems we need to know: _______________________________

请在以下您孩子计划来夏令营的星期划圈Circle the week(s your) child plans to attend:

” Week 1 (6/6--6/10) ” Week 2 (6/13--6/17) ” Week 3 (6/20--6/24)

” Week 4 (6/27--7/1) ” Week 5 (7/11--7/15) ” Week 6 (7/18--7/22)

” Week 7 (7/25--7/29) ” Week 8 (8/1--8/5) ” Week 9 (8/8--8/12)

Other Authorized Pick-up Person(s)

父母授权可接孩子的其他人

1)_______________________ 2) ______________________

父母签名Signature: _________________________

申请日期Date of application________