上海建平中学对外联络部.doc

上海交通大学老教授协会附属教卫学院(原上海交通大学思源进修学院)学生报名表姓名FamilyNameFirstNameMiddleName(2寸照片)国籍Nationality性别Sex婚否MaritalStatus出生日期年月日DateofBirthyearmonthday出生地点PlaceofBirth通讯地址HomeAddress电话Tel电子邮件CurrentEmail护照/()高中学历班()联考复习班FieldtoStudy学习期限自年月日到年月日DurationFrom(D)(M)(Y)to(D)(M)(Y)汉语学习经历ExperienceinLeaningChinese在沪监护人姓名及地址GuardianName&AddressinShanghai在沪住址&电话Address&TelinShanghai经济来源SourceofFunding家庭情况FamilyBackground申请人签字SignatureofApplicantDate:备注Remarks学生姓名NameofStudent家庭地址MailingAddress家庭电话号码PhoneNumber监护人Guardian姓名Name单位地址BusinessAddress手机号码CellNumberE-mail其他联系方法OtherContactNumber父亲Father姓名Name单位地址BusinessAddress手机号码CellNumberE-mail其他联系方法OtherContactNumber母亲Mother姓名Name单位地址BusinessNumber手机号码CellNumberE-mail其他联系方法OtherContactNumber学生家庭联络表学生健康表Withwhomdoesthechildreside(孩子和谁一起居住):Bothparents(双亲)____Father(父亲)____Mother(母亲)____Guardian(监护人)____Disease/Condition(疾病)Yes是No否Date日期Disease/Condition(疾病)Yes是No否Date日期Asthma哮喘Rheumaticfever风湿病Chickenpox水痘Scarletfever猩红热Colds(frequent)感冒(经常)Seizures(疾病的)发作Diabetes糖尿病Tonsillitis扁桃体炎Earinfection耳感染Whoopingcough百日咳Heartdisease心脏病Congenitaldeformities先天性畸型Hepatitis肝炎Other其它Pneumonia肺炎Surgery手术Allergies(food,medicine,other):_______________________过敏(食品、药物、其它):Date