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2022 Summer Program Registration Form
Pui Ying Art School 培英美术学校
2969 S. Archer Ave., Chicago, IL 60608 Ph # 773-289-7106
Registration Form - Must be completed for each student
报名表 - 每位学生要填妥下面的资料
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* Indicates required question
Student Information / 学生资料: Name 姓名
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Your answer
Date of Birth 出生日期
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MM
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DD
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YYYY
Age 年龄
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Your answer
Health Relation Information 健康资料
Your answer
Student School / 就读学校: Name 校名
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Your answer
Address 学校地址
Your answer
Family Information / 家庭资料: Name of Parents 父母姓名
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Your answer
Address 地址
Your answer
City 城市
Your answer
State 州
Your answer
Zip Code 邮区号码
Your answer
Home Ph 家里电话
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Your answer
Work Ph 工作电话
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Your answer
Cell Ph 手提电话
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Your answer
Relationship to student 与学生的关系
Your answer
Email:
Your answer
We Chat: 微信
Your answer
Emergency contact / 紧急情况可联络资料: Name (other than parent) 姓名（不同于父母）
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Your answer
Home Ph 家里电话, Work Ph 工作电话, Cell Ph 手提电话
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Your answer
Relationship to student 与学生的关系
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Your answer
I have read the tuition and enrolment policies and understand that there are no refunds for missed classes 我已经读过关于收费和注册的政策并明白缺课是没有退款的。(initial here)（填写姓和名的第一个大写字母）
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Your answer
I give permission for my children to receive medical treatment in case of emergency. 我允许让我的孩子在紧急情况下接受药物治疗。(initial here)（填写姓和名的第一个大写字母）
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Your answer
Teachers and volunteers accompany children to supervise their conversations when they go out to the countryside. 孩童出郊外话动其间均由老师及义工随行监管。
I authorize Pui Ying Art School to lead my child/children Name(s):___________ ___________ _ ____________to participate in this beneficial activity outside of the school building (field trip). In the event of an injury or emergency, the teachers are allowed to seek medical treatment for my child (children) or take him (her) to the nearest hospital. 本人授权培英美术学校带领我的孩子（孩子姓名）__________ _________ ___________ 参加本次署期有益活动。若遇紧急情况，本人准随行的导师为我的孩子寻求医治或送往最近的医院医治。
Your answer
Is the child (or children) allergic to any foods or medicines? Please select one 孩子是否对任何药物过敏？请选一项圈上
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Yes 是
No 否
Other:
If your child (or children) has any illness, please specify what illness 若果你的孩子有任何病，请详细写明什么疾病
Your answer
Your child's primary physician's name and contact information (phone number and address) 你的孩子的保健医生姓名, 电话, 地址.
Your answer
Company's name 公司名称
Your answer
Medical insurance number 医疗保险号码
Your answer
Parents’ Signature: Signature / 家长签名
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Your answer
Date 日期
MM
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DD
/
YYYY
签名（未成年孩子的家长）
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Your answer
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