上海威海路幼儿园国际部.doc

Photo here照片Wei Hai Kindergarten(International Division)No.730 Wei Hai Road, JingAn District, Shanghai 200041. Tel: (86-21) 6272 7877 Website: STUDENT APPLICATION FORM入学申请表Students Information学生信息Students Name: _ _ 学生姓名 First Name Middle Name Last Name Prefers to be called 名 中间名 姓 常用名Date of Birth: _ (MM/DD/YY) Sex: Female/ Male 出生日期 （月/日/年） 性别 女 男Place of Birth: _ Nationality: _ _出生地 国籍 Passport No.: _ Date of Expiry (MM/DD/YY): _护照编号 到期日 （月/日/年）First Language (Mother Tongue) Other Languages: _ _母语 其他语言Proficiency in spoken English (Circle one) Fluent Fair Some None英语口语程度（请画圈） 流利 普通 一些 不会说Proficiency in spoken Mandarin Chinese (Circle one) Fluent Fair Some None普通话口语程度 （请画圈） 流利 普通 一些 不会说Parents Information父母信息 Fathers Name: _ Nationality: _ 父亲姓名 First Name Last Name 国籍 名 姓Name of Company/Business: _公司/行业名称Office Tel. No.: 办公室电话Fax No.: _ Email address: _ 传真 电子邮件Home Tel. No.: _ Mobile: _家庭电话 移动电话Local Address: _本地家庭住址First Language (Mother tongue): _ Other Languages: _母语 其他语言Mothers Name: _Nationality: _母亲姓名 First Name Last Name 国籍 名 姓 Name of Company/Business: _公司/行业名称Title/Position: _ Office Tel. No.: _职务 办公室电话Fax No.: _ Email address: _ 传真 电子邮件Home Tel. No.: _ Mobile: _家庭电话 移动电话Local Address:_本地家庭住址First Language (Mother tongue): _ Other Languages: _母语 其他语言Educational Information教育信息1. Has the student been tested or recommended for any of the following (Please check)：学生有无以下情况（请打X） Slow learner 学习进度慢 Language and speech disorder 语言表达不清 Attention Deficit Disorder 注意力不集中 Autism 自闭症 Developmentally delayed 发展缓慢 Dyslexia 阅读障碍 Learning disability 学习障碍 Hyperactive 异常活跃多动 Psycholinguistic disorder 心理障碍 Emotional/behavioral disorder 情感/行为紊乱 Others其他Please explain any checked box(es) above: _请解释所选项_3. Has the Applicant attended a Montessori School in the past? Yes / No 学生有无就读过蒙特梭利学校？ 有/没有 If yes, which school：_ 如果有，学校名称：4. Please provide details for the above or any other factors that our school should be aware of that might affect the success of your child. 请提供上述信息的详细说明以及您认为学校需要了解的与学生成长相关的任何其他信息：_Personal Health information个人健康信息：1. Please indicate if your child has any physical condition that may require special attention. e.g. asthma如果您孩子的身体情况有任何需要特别注意的事项，请填写此项（例如：哮喘） _2. Is the child allergic to anything (e.g. penicillin, aspirin, milk, insect stings )?如果您的孩子有任何过敏史，请填写此项（例如：抗生素，阿司匹林，牛奶，昆虫叮咬）_3. Does your child take any medication routinely? Yes / No (If yes, please provide details)：您的孩子有无定期服用的药物？ 有/没有 （如果有，请提供详情）_School only allow the medicine which is the prescription ones by the parents. 学校给孩子服用的药必须是家长提供的处方药。4. Does your child wear glasses? Yes / No 您的孩子有无佩戴眼镜？ 有/没有5 Does your child have any limitations on physical activity? Yes / No您的孩子的体育活动方面有无特别限制？ 有/没有 If yes, please provide details：_ 如果有，请提供详情_ 6. Local Emergency Contact (other than parents): 本地紧急事故联系人 （除父母之外）l Name： _ _ 姓名 First Name Last Name 名 姓Relationship to Family： _ Mobile No.：_ 与家庭的关系 移动电话Home Tel. No.：_ Office Tel. No. _家庭电话 办公室电话l Name：_姓名 First Name Last Name 名 姓Relationship to Family： _ Mobile No.：_ 与家庭的关系 移动电话Home Tel. No.：_ Office Tel. No.： _家庭电话 办公室电话In the event of an emergency, do you agree to allow your child to have First-aid treatment at school? 在紧急事故发生时，您是否同意学校为学生提供简单急救？Yes / No同意/不同意7. In case requiring emergency medical attention and if we are unable to contact any of the above contacts,which hospital would you want us to take your child to for treatment? Please name the clinic or hospital. (Please refer to the listing below).假如学生发生紧急事故需要治疗，学校又无法与任何紧急联系人取得联系，请问您希望学校将您的孩子送往何处治疗？（请参照以下列表）If no hospital is listed, please give us your special instruction.如果您理想的医院/诊所未在此列表，请特别注明。 不能不年，MZXMXZCMNDCM，ZXBelow is a list of some hospitals and clinics in Shanghai:以下是学校附近的医院及诊所列表Childrens Hospital，Foreigners Section儿科医院 外事门诊183 Feng Lin Lu, 2nd Floor枫林路183号2楼 Tel: 5452-4666电话：5452-4666Hua Dong Hospital, Foreigners Section华东医院 外事门诊221 Yan An Xi Lu 延安西路221号Tel: 6248-3180电话：6248-3180Ruijin Hospital，Foreigners Section瑞金医院 外事门诊197 Ruijin Er Road瑞金二路197号Tel: 6437-0045电话：6437-0045Shanghai First Peoples Hospital，International Medical Care Center-上海第一人民医院 外宾门诊85，Wu Jin Road 武进路85号Tel: 6324-0090*2101电话：6324-0090*2101World Link，Shanghai Center Clinic瑞新国际医疗中心 上海商城诊所1376 Nan Jing Xi Lu. 203W 南京西路1376号，商城西峰购物区203室Tel: 6279-7688电话：6279-7688Hospital Choice:医院选择次序：1. _ 2. _3. _ _ School Fees Payment：学费及杂费：l School payments will be made by学费及杂费支付方 _l Queries for school fee payment should be directed to： 所有关于学校学费及杂费的疑问解答，处理方 _l School fee invoices and receipts should be mailed to: l 学费及杂费发票接收方 _I register my child for admission to Shanghai WeiHai Kindergarten-Montessori International Class for School Year _.我选择我的孩子 报读上海市威海路幼儿园的- 学年蒙特梭利国际班。Signature of Parent / Guardian: _ 家长/监护人 签名Date: _ 日期* Please hand in the form with both of the parents and your childs passport copy, 3 passport photos，birth certification and vaccination record.请将报名表连同学生及家长的护照复印件，3