Dr. Lang’s Chinese Bilingual School 2011 Summer Camp

郎艳霞2011双语学校夏令营

Full Day 5 – 12 years old - 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

现在年级：____________ 出生日：____________

Current Grade DOB

所在学校：_______________ 家庭住址：_________________________

School currently 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 (5/23--5/27) ” Week2 (5/31--6/3) (4 days) ” Week 3 (6/6--6/10)

” Week 4 (6/13--6/17) ” Week5 (6/20--6/24) ” Week 6 (6/27--7/1)

” Week 7 (7/5--7/8) (4 days) ” Week8 (7/11--7/15) ” Week 9 (7/18--7/22)

” Week 10 (7/25--7/29) ” Week 11 (8/1--8/5) ” Week 12 (8/8--8/12)

选择以下项目Select from the following programs

” Chinese Program (9:00-12:00) ” Enhancement Program (1:00-4:00)

中文课 英/数/科提高课

” Full-day Bilingual Program (9:00 – 4:00)

中文课及英/数/科

Authorized Pick-up Person(s)

父母授权可接孩子的人

1)_______________________ 2) ______________________

父母签名Signature: _________________________ 申请日期Date of application________