e - | Overseas Compatriot Affairs Commission

2010 ~C~yZW
Application Form for Language Study Program for Expatriate Youth
gWeA\UPWwC (Please read admission guidelines carefully before filling out the application form.) -^ a y
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NAME IN CHINESE

First ] Capital Letters ^ Last

Attach 2 Recent 1-inch

NAME IN ENGLISH

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DATE OF BIRTH

19
Month day year

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SEX

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Male

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Female

Photos Here

BIRTH PLACE

Capital Letters ^

NATIONALITY

HOME ADDRESS

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PASSPORT

E-mailG

EXPIRATION DATE

PLACE OF ISSUE

NUMBER

m W NAME
Ac
OFFICE

PARENTS

Give complete addresses only if different from home address above^

FATHER
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In Chinese^

MOTHER
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In Chinese^

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O. C. SOCIETY

TEL

FAX

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OFFICE

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NAME IN CHINESE

RELATIVE OR FRIEND FOR EMERGENCY CONTACT IN TAIWAN(Above age 20 ) ^ q TEL ] PHY ] ^ RELATION u FAX

WHICH PERIOD ARE YOU APPLYING FORH st Term] 1/4-2/14^

POSITION

WZ]-OZ^ @ | - WZ]^ Z LZ

th Term] 7/5-8/15^ th Term] 10/11-11/21^

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nd Term] 3/1-4/11^

T Teenagers Summer Term]

12/13-2011/1/23^

rd Term] 5/3-6/13^

7/6-8/16^

6th Term]
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WHICH PERIOD ARE YOU APPLYING FORH

Thailand] Indonesia]

3/22-5/2^ 6/21-7/18^

Philippines] 4/12-5/30^ Japan and Europe]

NO

7/26-8/22^

Do you have any of these diseasesH _ O_wUCefH zef e CHRONIC DISEASE, exG w EPILEPSY f

PSYCHOGENIC ILLNESS CARDIO-VASCULAR DISEASE

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Please do not apply for admission, if you have any of the above-mentioned diseases or any diseases which may affect the participation of the activity. If any of the above mentioned diseases is discovered after arriving in Taiwan, the student must leave immediately and pay his/her own medical and return expenses.
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Please note that all information must be completed; otherwise your application wont be accepted.


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ENROLLMENT AGREEMENT

As a student of the program, I am willing to observe and abide by all the regulations of the OCAC Language Study Program for Expatriate Youth. I understand that if I violate these regulations (see demerit regulations), I will accept the corresponding demerit. Once I have reached the demerit limits, I will unconditionally forfeit the right to study at the language center and will depart immediately upon request submitted by the Overseas Compatriot Affairs Commission
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Phone:

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Fax:

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Home address:

Date:

Students Signature:

Parents (Guardians) Signature:

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NoticesG
Students are allowed to register only with the Certificate of Admission.

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Students without cosigned Agreement by the parent will not be allowed to enroll.

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Frequency or Time Period Punishment or Point deduction B@ Dismiss h

In order to promote learning quality and to maintain students safety, the OCAC will administer the following group regulations.

Behavior

Theft (You will be reported to the police)(~Aek ) Sleeping in the room of the opposite sex overnight.]b^ Severe fights will be reported to the policeA and the payment for the full medical services must be made. ]Y- ek~A-tvd^ Drug taking will be reported to the police.(lrek ) Being late for bed-check.]IW^ Sick leaves. (f ) Leaving on personal matters.]^ Unexcused absence from class.]m^ Being late for class.]W^ Leaving class before dismissal.]W-h^ Not wearing nametag at any given time.]aWP^ If you didnt fill out any permission form ,it will result in a point deduction. (-YWwgAN|Z 0.5 ) Smoking in non-smoking areas.]bDl^ Being noisy after bed-check and failing to behave.]`nxAU^ Leaving the center without permission after bed-check.]IW~X^ Putting up people who are not presently students of this center in your room.]a~HiJJ^ Drinking, gambling, fighting with others during study period.]bsBM[^ Damaging public properties. (You will have to compensate for the damaged or lost according to its price.) ]}aAt v^ Staying in the room of the opposite sex after bed-check. (IWbrd ) Staying overnight without filling in the Overnight Absent Form. (~J ) Clean (b ) Room-check (d ) Messy ( )

Once @

One Hour @p

0.25 0.15 0.25 1 0.1 0.5

1 Once @ 2 4 + 0.5 - 0.5

If you win any competition held by the office during this term, your discipline points may be added 0.5 point. (p One + 0.5 @- GPU | oAC@i[ 0.5 ) Loudly playing music anytime.]-T-qLj^ Playing with dangerous articles, i.e. air gun/ toy gun/ laser pen. Confiscate the equipment until the end of the term]So^ ] MIApGj /j /pgj ..^ Alcoholic drinks. (ts )

1. Each student starts with 15 discipline points. Z ` Z 15%]Y 15 ^ 2. If you behave well and have no deduction during a whole week, your discipline points will be added 0.5 point. pg{}nBAgZ[ 0.5 C 3. If you need to ask for a leave, please report to the office staff or counsellors in advance. All leave-asking procedures should be submitted in three days including the day you ask for a leave or you will be considered as having a leave without permission. p iUH-A _ 3 zA_hHm C 4. If your discipline points are lower than 10 points, you will not be able to receive a graduate certificate nor will you be allowed to go on the graduation trip, nor apply for continuing study in the program. Students with discipline points lower than 7 points will be forced to leave the program immediately without reimbursement of the registration fee. ZF 10 Ao[~CAo~PNCF 7 } AO hC 5. If students are caught stealing, fighting or gambling (inside or outside of the center), the police may become involved at the discretion of the center. b ~oB[}ANp BzC

Tw-n OHWBNuUWwC I certify that I am willing to study languages and culture at this program, and that all of the above are true to the best my knowledge and that I will abide by all the rules and regulations of the center. @NuWwAe|vU-qw C I agree to comply with the guidelines and accept the study demerit regulations authorized by the OCAC and set by the designated school. HUgf^ ]
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Applicants Signature Please do not write below this line

FOR OFFICIAL USE ONLY^

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Parents Signature

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Reference Signature

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Date of applicationG f
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 e - | Overseas Compatriot Affairs Commission

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Items Required For Health Certificate i T- Valid for Three Monthsj
] Name in Chinese^

Date of Examination (M) ~ (Y)

Name in English

(D) Male k Female

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O X~

SexGk

@X y

Passport NoG NationalityG

Date of BirthG

Recent 1-inch Photos Here

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A.- B.i C. D. E.B HeightG PulseG Blood pressureG HeartG LocomotorsG `
/

PHYSICAL EXAMINATION
cm / time / min
@EW
mm Hg

F.- G.O H. ` `

WeightG VisionGk Hernia ` Abnormal Abnormal

Right Normal

Kg / Lb Left ` Abnormal

Normal Normal

LABORATORY EXAMINATIONS
Application missing this information will not be accepted.j
Chest -Ray for TuberculosisG Surface AntigenG ` Normal Positive ` Abnormal Negative Hepatitis

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A.d B.x-d

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A.f B.f C. D.}f GHW Heart diseaseG AsthmaG HypertensionG DiabetesG

MEDICAL HISTORY
Have you ever had the following diseases H E.w EpilepsyG Yes No O Is Yes Yes Yes No No No
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Yes Yes Yes Yes O Is not

No No No No XC fit.

F.f G.e H.xf pjdGAL

Kidney diseaseG MalariaG Liver DiseaseG

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CONCLUSIONG Above is the medical report of Mr. / Ms

He / She

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PhysicianG
e Name & Signature f

Hospitals or Clinics NameB AddressB Tel

|-tdH SuperintendentG
e Name & Signature f

DateG

(D)

(M)

(Y)