PDF《The SMIC PRIVATE SCHOOL 上海市民办中芯学校》

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9 The SMIC PRIVATE SCHOOL 上海市民办中芯学校 Contact Information 联络信息 A. Parent / Guardian

1 父母/监护人

1 Name 姓名: (English 英文) Last Name 姓First Name 名(Chinese 中文) Relationship to Applicant 关系 Citizenship 国籍 Language 语言 Phone

电话: (H 宅)M 手机) E-mail 邮件: Employer 工作单位: Department and Job Title 部门和职务: Employee Number (Only for SMIC Employees) 员工号码 (中芯员工必填) B. Parent / Guardian

2 父母/监护人

2 Name 姓名: (English 英文) Last Name 姓First Name 名(Chinese 中文) Relationship to Applicant 关系 Citizenship 国籍 Language 语言 Phone 电话 (H 宅)M 手机) E-mail 邮件 Employer 工作单位 Department and Job Title 部门和职务 Employee Number (Only for SMIC Employees) 员工号码 (中芯员工必填) Applicant'

s Residential Information 申请人的居住信息 * Applicant must reside with at least one of the guardians. 申请人须与上表所列的监护人中的至少一人住在一起. Address in Shanghai_Zip Code: 上海地址 邮编 Home Phone 家庭

电话: FAMILY INFORMATION The SMIC PRIVATE SCHOOL 上海市民办中芯学校 Page

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9 Permission to Release Records I hereby grant permission to the SMIC Private School to ask for and receive confidential records, including academic, medical, and/or disciplinary records, for my child,who was an enrolled student at the name of school), during the year of Signature of Parent/Guardian:Date: 授权书 本人承诺授权于上海市民办中芯学校,对该校所收到的学生个人资料,包括学籍卡、成绩单、健康报告 以及行为表现等记录,可以向学生原来所在学校查询、调查. 同学于_年曾就读于_学校 家长签名:日期: Please return this permission form to: 请将这份授权书寄回至: The SMIC Private School, Shanghai 中国上海浦东新区青桐路

169 号 邮编:

201203 Admissions Office MHS A119 上海市民办中芯学校

169 Qing Tong Road 招生办公室, A119(中学部) Pudong New Area, Shanghai, China

201203

电话:86-21-5855-4588 x

228 (T): 86-21-5855-4588 x

228 传真:86-21-5855-7462 (F): 86-21-5855-7462 电子

邮箱:[email protected] E-Mail: [email protected] Page

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9 The SMIC PRIVATE SCHOOL 上海市民办中芯学校 Emergency Contact Information(健康信息与紧急联络表) 学生姓名: 出生日期 性别 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: 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: 良好 普通 不佳 General Health Status: Good Average Poor 1. 需要让学校知道的健康相关状况,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.) Has your child been prescribed with any long-term medications? 3. 过敏物 Allergies: 食物 Food 药物 Drugs 其他 Other The SMIC PRIVATE SCHOOL 上海市民办中芯学校 Page