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明志科技大學115年度USR計畫活動「在地X全球：暑期文化交流營隊」報名表 Ming Chi University of Technology 2026 USR Program Activity “Local × Global: Summer Cultural Exchange Camp” Registration Form
家長同意書可於營隊期間繳交即可:
  The parental consent form can be submitted during the camp period:  
點此下載家長同意書
Click here to download the parental consent form.  
 weishih@mail.mcut.edu.tw

一、報名時間及費用：即日起至115年7月31日（星期五）下午5時前，參加費用全額免費。

二、錄取名單公告：錄取名單於115年8月7日(星期五)下午5時前於明志科技大學網站首頁
及新北市國際教育資訊網(https://www.international-education.ntpc.edu.tw/home)公告。

明志科大國際處USR團隊
  USR Team, Office of International Affairs, Ming Chi University of Technology  
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2025年活動影片  2025 Event Recap Video
營隊活動海報 Sumer Camp Poster
英文姓名（若有護照請依照護照填寫）
 English Name (as shown on passport, if available)  
 *
性別 
Gender
*
出生年月日（西元格式）
Date of Birth (YYYY/MM/DD)  
 *
身分證字號  
National ID Number
*
國籍  
Nationality
*
就讀學校全名 
Full Name of School
 *
年級（升幾年級）
Grade Level (Grade to be entered)
 *
手機號碼（本人） 
Mobile Phone Number (Applicant)
 *
家中電話（市話） 
Home Phone Number (Landline)
 *
學生Email 
Student Email Address
 *
家長/監護人姓名
Parent/Guardian Name
 *
家長/監護人聯絡電話
Parent/Guardian Contact Number  
 *
家長Email（用於重要通知）
Parent Email (for important notifications)
 *
緊急聯絡人姓名
Emergency Contact Name
 *
緊急聯絡人電話 
Emergency Contact Number
 *
通訊地址（含郵遞區號）  
Mailing Address (including ZIP Code)
 *
是否參加過本計畫去年的營隊 ？
Have you participated in the same camp last year? 
 *
是否有過敏體質（食物／藥物等，請詳述） ？
Do you have any allergies (e.g., food, medications)? Please describe in detail.
 *
是否需長期服藥（請提供藥物名稱與用法） ？
Do you require long-term medication? (Please provide the medication name and usage instructions.)
 *
是否有慢性疾病或特殊健康狀況（請詳述） ？
Do you have any chronic illnesses or special health conditions? (Please describe in detail.)
 *
是否曾有重大手術或住院史？
Have you ever had any major surgeries or hospitalizations?
 *
是否有心理健康需求（如焦慮、憂鬱症狀等）？
Do you have any mental health needs (e.g., anxiety, depression symptoms)?
 *
飲食需求？
Dietary Requirements
 *
英語程度
English Proficiency
 *
其他語言能力（請列出語言與程度）
Other Language Proficiency (please list the language(s) and level(s))
個人興趣／專長（如戲劇、音樂、體育、科學等）
Personal Interests / Special Skills (e.g., drama, music, sports, science, etc.)
 *
報名本營隊的動機（開放式回答）
Motivation for applying to this camp (open-ended response)
 *
家長／監護人同意事項
本人已詳細閱讀活動內容，並同意學生參加本次營隊

Parental/Guardian Consent Statement
I have carefully read the activity details and agree to allow the student to participate in this camp.

 *
家長／監護人同意事項
同意主辦單位於活動中拍攝之照片或影像作為活動紀錄或成果展示用途
Parental/Guardian Consent Statement
I agree that photos or videos taken during the activity may be used by the organizer for documentation or presentation purposes.
 *
Required
家長／監護人同意事項
同意主辦單位於必要時可聯絡醫療單位處置突發健康狀況
Parental/Guardian Consent Statement
I agree that, if necessary, the organizer may contact medical services to handle any unexpected health conditions.
 *
Required
家長／監護人同意事項
同意遵守活動相關規範與安全指引 
 Parental/Guardian Consent Statement
I agree to comply with all activity regulations and safety guidelines.  
 *
  衣服尺寸（請選擇）
 T-shirt Size (please select one)   *
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