2025 Summer Program Registration Form Student English Name * 學生姓名 First Name Last Name Student Chinese Name 學生中文名字 First Name Last Name Age * 年齡 Gender * 性別 Male Female Date of Birth * 出生日期 MM DD YYYY Total Number of Weeks Enrolled * 参加週數 1 2 3 4 5 6 7 8 Select Camp Week(s) * 夏令營時間 Week 1: 6/23 – 6/27 Week 2: 6/30 – 7/4 Week 3: 7/7 – 7/11 Week 4: 7/14 – 7/18 Week 5: 7/21 – 7/25 Week 6: 7/28 – 8/1 Week 7: 8/4 – 8/8 Week 8: 8/11 – 8/15 Time in Camp * Full-Day (9 AM - 4 PM) Half-Day (9 AM - 12 PM) Afternoon (1 PM - 4 PM) Does the student require extended care (4PM - 5PM)? * 學生是否需要延長照顧（下午4點至5點）？ Yes 是 No 否 Does the student require school lunch? * 學生是否需要學校午餐？ Yes 是 No 否 Chinese Language Level * 1 - None 2 - Beginner 3 - Intermediate 4 - Advanced Grade entering in September * 在校年級 Number of Children Enrolled * 註冊兒童數量 Family Information 家庭情況 Father / Guardian Legal Name * 父親或監護人姓 First Name Last Name Father / Guardian Chinese Name 父親或監護人中文名 First Name Last Name Email * 電子郵件 Phone * 電話 (###) ### #### Mother / Guardian Legal Name * 母親或監護人姓名 First Name Last Name Mother / Guardian Chinese Name 母親中文名 First Name Last Name Email * 電子郵件 Phone * 電話 (###) ### #### Emergency Contact Information 緊急聯繫人 Name * 姓名 First Name Last Name Email * 電郵 Phone * 電話 (###) ### #### Relationship * 緊急聯繫人與學生的關係 Allergies * 學生有無過敏食物? 若有，請列出食物名稱： Peanuts Fish / Shellfish Eggs Peanuts or nut butter Tomato products Milk Peanut or nut oils Tree nuts (walnuts, almonds, pecans, etc.) Other (please specify) Media Consent 媒體同意書 Do you consent to grant permission to Little Lotus Academy to use my child's image (photographs and/or video) for use in school website or other media publications? * 您是否同意授權小蓮花學校使用我孩子的圖像（照片和/或影片）於學校網站或其他媒體出版物？ I Consent. 我同意。 I do not consent. 我不同意。 Parent / Guardian Signature * 家長或監護人簽名 Health Examination Form 暑期班體檢表 Health History 病史 Please answer Yes/No. Provide dates if answered “Yes.” 是/否 (如回答“是”，請在右邊線上填寫相應的時間) Has/does the student: 營員: 1. Had any recent injury, illness or infectious diseases? * 最近有受傷、生病、或傳染性疾病？ No 否 Yes 是 2. Have a chronic or recurring illness/condition? * 慢性或複發型疾病/病症？ No 否 Yes 是 3. Ever been hospitalized? * 住過醫院？ No 否 Yes 是 4. Ever had surgery? * 動過手術？ No 否 Yes 是 5. Have frequent headaches? * 經常頭痛？ No 否 Yes 是 6. Ever had a head injury? * 頭部受過傷？ No 否 Yes 是 7. Ever been knocked unconscious? * 曾經撞倒無意識？ No 否 Yes 是 8. Wear glasses, contacts, or protective eyewear? * 佩帶眼鏡、隱形眼鏡或防護眼鏡？ No 否 Yes 是 9. Ever had frequent ear infections? * 頻繁的耳部感染？ No 否 Yes 是 10. Ever been injured during or after exercise? * 曾經有過在運動中或之後受傷？ No 否 Yes 是 11. Ever been dizzy during or after exercise? * 曾經有過運動期間或運動後頭暈? No 否 Yes 是 12. Ever had seizures? * 是否有過癫痫發作？ No 否 Yes 是 13. Ever been diagnosed with a heart murmur? * 被診斷有心藏雜音？ No 否 Yes 是 14. Ever had back problem? * 有否腰背問題？ No 否 Yes 是 15. Ever had problem with joints (ex. knees, ankles)? * 關節問題（如膝、腳踝)？ No 否 Yes 是 16. Have an orthodontic appliance being brought to camp? * 矯形器具帶到營地？ No 否 Yes 是 17. Wear braces? * 帶護腕否? No 否 Yes 是 18. Have any skin problems (eg. itching, acne, rash)? * 皮膚疾病（搔癢、痤瘡、皮疹）？ No 否 Yes 是 19. Have diabetes? * 糖尿病？ No 否 Yes 是 20. Have asthma? * 哮喘？ No 否 Yes 是 21. Had mononucleosis in past 12 months? * 過去十二個月有單核細胞增多症？ No 否 Yes 是 22. Had problems with diarrhea/constipation? * 有否腹瀉/便秘？ No 否 Yes 是 23. Have problems sleepwalking? * 夜游症？ No 否 Yes 是 24. If female, have an abnormal menstrual history? * 女性，有否不正常月經史？ No 否 Yes 是 25. Have a history of bedwetting? * 是否尿床？ No 否 Yes 是 26. Have ADD/ADHD? * 注意力缺陷/注意多動症？ No 否 Yes 是 27. Have OCD/ODD? * 強迫症/對立違抗性障礙？ No 否 Yes 是 Does the student have insurance? * 學生有沒有醫療保險？ Yes 是 No 否 Thank you!
