中芯(中文部报名表)

小学部 中国上海浦东新区青桐路19弄3号 中学部 中国上海浦东新区青桐路169号 邮编：201203E l e m e n t a r y D i v i s i o n N o. 3, La n e 19 Q i n g t o n g Ro a d M i d d l e /H i g h S ch o o l D i v i s i on No. 169 Qingtong Road P u d o n g N e w A r e a Shanghai, China 201203(tel) 86-21-5855-4588 x 228 • (fax) 86-21-5855-7462 • 中文部入学申请表格Application For Chinese Track请每个申请人提供完整无缺的申请材料，申请材料将不予退还。

申请人姓名(中文Chinese Name ): _________________________(英文姓名English Name ) ______________________________________申请年级Applying for Grade: ______ 现在年级 Current Grade ____常态班_____ 英文侧重班_____ 预计到校日期: ________________性别Gender: M 男 / F 女 出生日期Birth date: ______/____/____ 年 月 日籍属 ____________ 国籍/护照号码 Nationality/Passport #: _______ /__________________签证到期日期Visa Expiration Date :__________________ 出生地Place of Birth : _____________学习经历 （Education ）学校 School 年级 Grades 起止日期 Period家长/监护人 信息 （Parent / Guardian ）姓名 Name关系 Relationship籍属 citizenship工作单位及职务Employer & Title联络方式 (Contact Information ）z 家庭住址 Shanghai Address _______________________________________邮编__________z 家庭电话 Home Phone _____________ 手机 (cell) 父 ________________母_______________z 家长电邮箱 E-mail 父____________________________母__________________________********************************************************************************************************* For Admissions Office Only 学校行政专用____ Application Form ____ Parents Admissions Survey ____ Medical History ___ Passport ___Visa____ Photos ___ Report Cards SMIC Employee # _______________Received by ________________ Date: _____________*******************************************************Test Date ____________ Accepted _____ Rejected _____ Conditional Acceptance ______PARENT’S ADMISSIONS SURVEY家长调查表To the Parents: We would like to get a full profile of your child, in order to see that our school is a good fit for your child’s needs and abilities, and to insure a successful transition to SMIC Private School if he/she is admitted. Please answer the following questions as completely and candidly as you can.学校为提供优质服务,更全面地了解您孩子的需求和状况, 请如实准确地回答如下问题1.Tell us about your family situation家庭状况:___ Two Parents, both working双职工 ___ Two Parents, one at home双亲,一位在家___ Single Parent, at home单亲, 无工作 ___ Single Parent, working单亲, 工作2.Tell us about your child—are any of the following special issues? （Yes or No）特别事项 (请回答是或否)___ Is he/she receiving any special treatment for physical problems? 身体上有过特别治疗吗?___Is he/she receiving any special treatment for psychological problems or learning disabilities？精神和学习上有过特别治疗吗?___Does he/she have any allergies or medical conditions of which we should be aware?有食物过敏或其他学校应知道的医疗状况吗?___Any other things we should know about the needs of your child? (其他事项)_________________________________________________________________________________ ____________________________________________________________________________________________I have filled out this form truthfully and to the best of my ability. I understanddeliberate falsification of information relative to my child may result in refusal of SMIC Private School to accept the child, or if accepted, may result in subsequent dismissal from the school.我所填写资料全属真实，我明白若有不实之处，学校将不予录取，录取后若发现不属实，亦将遭学校退学之。

Signature of Parent/Guardian家长签字: _____________________ Date日期:____________小学部 中国上海浦东新区青桐路19弄3号 中学部 中国上海浦东新区青桐路169号 邮编：201203E l e m e n t a r y D i v i s i o n N o. 3, La n e 19 Q i n g t o n g Ro a d M i d d l e /H i g h S ch o o l D i v i s i on No. 169 Qingtong Road P u d o n g N e w A r e a Shanghai, China 201203(tel) 86-21-5855-4588 x 228 • (fax) 86-21-5855-7462 • EMERGENCY CONTACT INFORMATION（健康信息与紧急联络表）学生姓名: 出生年月日 性別Student Name: _________________ Birth Date: __________ Gender: ____(Family Name, First Name, M.I)(Month, Date, Year)(M/F)血型系列： 年级Blood Type: ___Track: _________ Grade: ______在中芯学校或幼儿园就读\即将就读的兄弟姊妹：Siblings attending The SMIC Private School and/or Kindergarten:姓名 系列： 年级Name: ___________________________ Track: ____________ Grade: _________ Name: ___________________________ Track: ____________ Grade: _________ Name: ___________________________ Track: ____________ Grade: _________紧急联络人(若学生发生紧急事故,学校将依您填写的联络人顺序联络)Please list 3 contacts in case of an emergency (Contacts will be notified in the order they are listed):姓名 关系 电话 语言 Name Relationship to Student Phone Number(s) Language(s) Spoken平时健康情形:General Health Status: 1.需要让学校知道的健康相关狀況，健康问题或特殊疾病:Does your child have any health problems/conditions that the school should be aware of?2. 长期服用之药物和特殊用药？（长期服用之药物和特殊用药，需由家长为孩子准备随身携带。