China Study Abroad

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NAME:

Last: (Surname)
*

First: (Given)
*

Middle:

Title:

Gender:
Male FeMale

CHINESE NAME - If you have one. If not, we will assign you one.

Characters:
Click here to get Chinese character input software or here for MS Global IME

Pin Yin:

PROGRAM:

City: (choose first)
University Applying for:

Program Selection:

Program Duration:

Program Start Date:

Program End Date:

Program Hours:

Standard(details) Intensive (details)

Program Code: (details)

ACCOMMODATION:

Accommodation Choice:

Accommodation Start Date:

Accommodation End Date:

Do You Smoke?:

yes no

Do you prefer to live in a non-smoking room?:

yes no doesn't matter

CURRENT ADDRESS:
Street/Apt.# District:
City:		State/Province:
Country:		Zip/Postal Code:
PERMANENT ADDRESS: 1 Check if same as CURRENT ADDRESS
Street/Apt.# District:
City:		State/Province:
Country:		Zip/Postal Code:
TELEPHONE / FAX / E-MAIL:
Home Telephone: (with country code)		Work Telephone:
Fax:		Cell Phone :
E-mail:	*

PERSONAL INFORMATION: (All information will be kept confidential. For more info see our Privacy
Date of Birth:		Age Range:	Under 18 18-65 Over 65
City of Birth:		Marital Status:	Single Married
Native Language:		Nationality: (Passport Country)
Country of Birth:	Same as Nationality	Not the same, Please Fill in:
Passport #:		Expiration Date:

ACADEMIC INFORMATION:
Educational Level:		Current or Last School:
Date you attended/completed most recent academic institution:
EMPLOYMENT:
Occupation:		Current or Last Employer:
Date you worked for most recent employer:
MEDICAL CONDITIONS / DIETARY REQUIREMENTS:
Please tell us about any allergies, medications, chronic conditions etc.:

Please tell us about any special dietary requirements: Vegetarian, Vegan, Kosher, Muslim etc.:

EMERGENCY CONTACT:
First Name: (Given)	*	Last Name: (Surname)
Relationship to Applicant:		Occupation:
Home Telephone:		Employer:
Work Telephone:		Fax:
E-mail:
Address:
City:		State/Province:
Country:		Zip/Postal Code:
Will this person also serve as your financial guarantor in China: yes no
Name of Financial Guarantor: (if different from Emergency Contact)
Relationship to Applicant:		Occupation:
Home Telephone:		Employer:
Work Telephone:		Fax:
E-mail:
Address:
City:		State/Province:
Country:		Zip/Postal Code:

CURRENT LEVEL OF MANDARIN CHINESE:
Have you previously studied the Chinese Mandarin language?: yes no
If yes, please state the name of the institution / School:
Hours Studied Per Week:		Level:
Approximately how many Simplified Characters do you know?:		Traditional Characters:
Other Chinese Dialects Known:	Cantonese Shanghainese Others
Do you require an official Transcript for credit?: yes no
Are you receiving credit for this course from your university?:		how many credit hours
FOR MARTIAL ARTS ONLY:
List Preference of form(s) or style(s):
Level and Years of Experience:
HOW DID YOU HEAR ABOUT US:
Method:		Detail:
Have you participated in another China Study Abroad program before?: yes no
ADDITIONAL COMMENTS:
Please include any additional information you feel we should be aware of (i.e. Joint Application - state name of joint applicant; other requests regaring accomodation etc.):
APPLICANT SIGNATURE:
I declare that: The above information provided and documents given in support of my Application are complete, true and correct. I agree to abide by the laws of the People's Republic of China and agree not to engage in any illegal activities during my academic pursuit in China. I have read and I accept China Study Abroad's Terms and Conditions for Program Participants. I agree to observe and accept all Rules, Regulations and Conditions of the host schools / institutes / organizations. I have read and I accept the Terms and Conditions for Insurance and Medical Membership .

ELECTRONIC SIGNATURE OF APPLICANT OR PARENT (for ages 17 and under)
I agree with the declarations stated above: yes no