ASSE Registration - 遠景安 Bright Future Education

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前往國家 Country applying for

姓氏 Family Name

名字 Given Name(s)

英文小名 Nickname (if any)

地址（區、街道名稱、門牌號碼）Street Address

城市 City

州/省 State/Province

郵遞區號 Zip/Postal Code

國家 Country

生日 Birthday (Please type month in letters)

出生城市 City of Birth

出生國家 Country of Birth

國籍 Citizen of (Country)

合法永久居民 Legal Permanent Resident of (Country)

電子信箱 E-mail Address

家用電話（包括區碼）Phone Number with City/Area Code

身高 Height

體重 Weight

眼睛顏色 Eye Colour

頭髮顏色 Hair Colour

性別 Gender

男 Male

女 Female

宗教信仰（若有） Religious Preference (if any)

你熱衷於宗教信仰嗎？ Are you religious?

非常虔誠 Very Active

普通 Active

不熱衷 Inactive

父親或法定監護人 Father or Legal Guardian

姓氏 Family Name

名字 Given Name(s)

地址 Address

城市 City

州/省 State/Province

郵遞區號 Zip/Postal No.

國家 Country

職稱 Occupation/Title

年齡（選填）Age (Optional)

家用電話（包括區碼）Phone Number with City/Area Code

手機號碼 Cell/Mobile Phone Number

母親或法定監護人 Mother or Legal Guardian

姓氏 Family Name

名字 Given Name(s)

地址 Address

城市 City

州/省 State/Province

郵遞區號 Zip/Postal No.

國家 Country

職稱 Occupation/Title

年齡（選填）Age (Optional)

家用電話（包括區碼）Phone Number with City/Area Code

手機號碼 Cell/Mobile Phone Number

緊急聯絡人（父母/監護人以外之親戚或朋友） Nearest relative or friends to contact, in case of emergency, if parent or legal guardian is not accessible

姓名 Name

家用電話（包括區碼）Phone Number with City/Area Code

關係 Relationship

兄弟姊妹 Brother(s) and Sister(s)

姓名 Name(s)

年齡 Age

性別 Gender

校名/職稱 School/Occupation

是否住在家？ Living at Home?

是 Yes

否 No

姓名 Name(s)

年齡 Age

性別 Gender

校名/職稱 School/Occupation

是否住在家？ Living at Home?

是 Yes

否 No

姓名 Name(s)

年齡 Age

性別 Gender

校名/職稱 School/Occupation

是否住在家？ Living at Home?

是 Yes

否 No

姓名 Name(s)

年齡 Age

性別 Gender

校名/職稱 School/Occupation

是否住在家？ Living at Home?

是 Yes

否 No

姓名 Name(s)

年齡 Age

性別 Gender

校名/職稱 School/Occupation

是否住在家？ Living at Home?

是 Yes

否 No

請問你是否參加社團？若有，是什麼社團呢？Are you a member of any club(s)? If so, which?

請列出你的嗜好，興趣，參與的運動（以重要程度依序排列）List hobbies, interests, and sports in which you participate, all in order of importance to you:

請問你會唱歌或演奏樂器嗎？如果會，請敘述之： Do you sing or play a musical instrument? If yes, please describe:

請問你在家負責什麼家事？What are your normal household responsibilities?

請敘述你的打工/志工經驗： Indicate any part-time jobs and work/volunteer experience you may ever had:

你曾經當過交換學生嗎？若有，是去哪一個國家？Have you ever been an exchange student before? If yes, which country(ies)?

你為什麼想成為交換學生？Why do you choose to become an exchange student?

請列出你會說或曾經學過的語言 Indicate the foreign languages you speak and/or have studied

語言 Language

學習時間（年）Years of Study

請勾選現在/曾經罹患的疾病 Indicate with an X if you have or have had any of the following illnesses

若你罹患上述疾病，請問有任何一項之嚴重程度足以需要將你安置在一個「正常」家庭以給予定期治療或特殊照顧嗎？請解釋(情節嚴重的話)：If yes, are any of the above serious enough to warrant regular treatment or require special consideration in hosting you by a 'normal' host family? Please explain (if serious):

若你必須在國外期間服用處方藥物，請詳細說明藥物名稱與用途：If you will be required to take any prescription medication(s) during your stay, please specify which medication(s) and for what condition(s):

你是素食主義者嗎？Are you a vegetarian?

是 Yes

否 No

若是，由於尋找願意接待素食學生的家庭可能比較困難，請寫下你絕對無法或不願意食用的食物：If yes, as it may be more difficult to find families to host vegetarian students, please indicate which foods you are absolutely unable or unwilling to eat:

Radio Buttons

Radio 1

Radio 2

Radio 3

當安置你於接待家庭時，請問有其他我們該考慮的健康、飲食或身心狀況嗎？ Do you have any other health, dietary, physical or emotional condition(s) that should be considered when we are placing you in a host family?
（請留意這樣的狀況可能會限縮願意或可以接待你的家庭數量）(Keep in mind that such conditions may limit the number of families willing or able to host you.)

ASSE/WH計畫規定與同意書 ASSE/WH STUDENT PROGRAM RULES AND CONSENT AGREEMENT

學生簽名 Signature of Student

日期 Date

父親/母親/法定監護人簽名 Signature of Parent/Legal Guardian

日期 Date

父親/母親/法定監護人簽名 Signature of Parent/Legal Guardian

日期 Date