Spring 2019, YBB China Culture Exploration Program

I. Student Information

* Indicates required field

Name *

First

Last

Birthday: (mm/dd/yyyy) *

Gender *

Male Female

School *

Grade *

Student Cell Phone Number *

Email *

Home Address *

Line 1

Line 2

City

State

Zip Code

Country

II. Parent Information

Mother's Name *

First

Last

Email *

Cell Phone Number *

Home Phone Number *

Office Phone Number *

Father's Name *

First

Last

Email *

Cell Phone Number *

Home Phone Number *

Office Cell Phone Number *

III. Medical Insurance:

Insurance Company Name: *

Insurance Group Name: *

Insurance Policy No: *

Insurance phone number *

Insurance Fax Number *

Insurance Address *

Line 1

Line 2

City

State

Zip Code

Country

IV. Primary Doctor:

Primary Doctor Name: *

Primary Doctor Phone Number: *

V. Dentist:

Dentist Name: *

Dentist Phone Number *

VI. Emergency Care Information and Consent to Enroll

I certify that I fully understand the general rules of C&T Youth Technology Academy (CTYTA) and I agree to obey such rules. In case of an emergency, CTYTA has my permission to take my child to the emergency room of the nearest hospital if I cannot be contacted, and the hospital staff has my authorization to provide treatment that a physician deems necessary for the wellbeing of my child. I, for myself, my heirs, personal representatives, or assigns, do hereby release, waive, and discharge CTYTA, its officers, directors, employees, and agents from liability from any and all claims, including but not limited to, physical or mental injury, illness, death, and property loss arising, from participation in activities of CTYTA. I also understand my image may be used in all photos, video and other media under the YBB program. I consent to have my picture taken and used for YBB related content and materials.

VIII. Short Answers:

Please fill out the questions below

1. What's your Chinese level? (Chinese not required) *

None Beginner Intermediate Expert

2. In a few words, describe yourself *

3. Why are you interested in this program? What can you contribute? What do you hope to gain? *

4. What aspect of Chinese culture most interests you? What do you want to learn more about? *

Student signature: *

Date: (mm/dd/yyyy) *

Parent or guardian signature: *

Date: (mm/dd/yyyy) *

SUBMIT