財團法人國語日報社附設臺北市私立國語短期補習班 Mandarin Daily News Language Center 2015 臺灣小旅行-華語研習營報名表 “A Sip of Life in Taiwan”2015 - Mandarin Learning Program Registration Form 班隊期程：2015/6/21～2015/7/5 中文姓名 Chinese Name 會注音符號還是拼音? Do you know ㄅㄆㄇ英文名字 English Name 生日 Date of Birth □ 注音符號ㄅㄆㄇ or PinYin ? 年(Y) 月(M) 日(D) □ 拼音 PinYin 預計來臺日期 Expected Date of Arrival ☐國語日報網站 MDN website 注意事項 Special Notes 課程資訊來源 ( 如：食物過敏 ex: How do programs? allergies) you ☐親友介紹 know our Friends/ relatives referral ☐其他 others 永久地址 Permanent address 護照號碼 Passport No. 報名前必讀！報名後，視同同意以下退費辦法。國籍 Nationality 退費辦法 (依照臺北市教育局退費規定) : 1) 開課日前, 第 60 天前 : 退費 95% 性別 Gender 2) 開課日前, 第 59‐至第 1 天前 : 退費 90% 母語 Mother language 3) 開課後, 第 2 天 (或次) 上課前 : 退費 70% 家長/監護人姓名 Parent/Guardian’s name 4 ) 開課後, 上課總時數未達 1/3 : 退費 50% 電子郵件 Email address 5) 開課後, 上課總時數達 1/3 : 恕不退費 Must Read! Before hand in the registration form. 聽 ☐佳 ☐普通 ☐尚可 ☐完全不會 Refund Policy (based on the rules of the Taipei City Government) : 中文程度 (必填) 說 ☐佳 ☐普通 ☐尚可 ☐完全不會 1) Cancellation, 60 days before the class starts : 95% refund Chinese level 讀 ☐佳 ☐普通 ☐尚可 ☐完全不會 2) Cancellation, 59-1 days before the class starts : 90% refund 寫 ☐佳 ☐普通 ☐尚可 ☐完全不會 3) Cancellation, before 2nd day/time of the class : 70% refund 4) Less than 1/3 of the total class hours: 50% refund 學習中文時間 (必填) 年 Years Years of Chinese study 小時/每週 Hours per week 5) More than 1/3 of the total class hours: no refund 報名需繳交填妥的報名表和家長同意書（次頁）。 Please fill out the registration form & Waiver on next page to apply the program. 1/2 請閱讀以下同意書，填寫內容並簽名，謝謝！Please fill out the permission & waiver and sign, thank you. 家長同意書本人已經瞭解國語日報社語文中心辦理之 2015 臺灣小旅行華語研習營活動之活動內容及規定，並同意（參加學生姓名）參加該活動，自 2015 年 6 月 21 日至 2015 年 7 月 5 日。（參加學生姓名）絕對遵守活動中之每項規定，並聽從活動活動期間，本人保證人員之指示及安排，對於營隊所有活動皆熱心參與之。如活動期間內，發生緊急情況或意外時，若家長/監護人不在現場，本人同意接受主辦單位進行一切必要之處理及措施，並對主辦單位處理過程與結果不追究任何責任。家長/監護人簽名：聯絡電話： ____年月日 Permission and Waiver I hereby give consent for my child named __ ___ _________ to attend “A Sip of Life in Taiwan” 2015 ‐ Mandarin Learning Program of Mandarin Daily News Language Center, from June 21st, 2015 to July 5th, 2015. I have read the description of the “A Sip of Life in Taiwan”2015 ‐ Mandarin Learning Program offered by Mandarin Daily News Language Center and understand that activities will be involved in my child’s program and find them acceptable for my child’s participation. During the program, I hereby guarantee __ ___ _________ shall obey any rules of all the activities of other related events, also follow up the instruction and arrangement of the staff or instructors, and enthusiastically participate all the activities of this “A Sip of Life in Taiwan”2015 ‐ Mandarin Learning Program. In the event of any emergency that I am not present, I hereby give my permission to the medical personnel selected by the camp director to order treatment and necessary transportation for my child. By signing below, I, the parent/guardian, do hereby agree to release, indemnify and hold harmless the staff of Mandarin Daily News Language Center for any loss, injury or damage resulting directly or indirectly from my child’s participation in this program. Parent / Guardian Signature / / Month / Date / Year 2/2