Intent Survey Form - Aurora
The Intent Survey Form will help Great Wall Chinese Academy's planning on offer Chinese program (after-school, weekend school) in Aurora area. All information on this form is strictly confidential and for the school use only.

Great Wall Chinese Academy website: http://greatwallchineseacademy.org/

Student 学生
Student Name *
英文姓名 Last name, First name
Your answer
Chinese Name *
中文姓名, if student does not have Chinese name, repeat English name here
Your answer
Sex *
性别 Female, Male
Birthday *
生日 YYYY-MM-DD
Your answer
Interests *
Required
Class Option *
Intent to take what classes, check all that apply
Required
Grade *
Grade in day school or home school currently
Ethnic Group *
族别
Required
Family 家庭
Home Phone *
Home Phone 家庭电话
Your answer
Street *
Street Address
Your answer
City *
Your answer
Zip *
Your answer
Mother
Last name, first name; 母亲姓名: 有中文姓名, 请填中文姓名
Your answer
Mother's Occupation
Your answer
Mother's Phone
Cell Phone 联系电话
Your answer
Father
Last name, first name; 父亲姓名: 有中文姓名, 请填中文姓名
Your answer
Father's Occupation
Your answer
Father's Phone
contact phone
Your answer
Mother's Email
Contact Email 电子邮件
Your answer
Father's Email
Contact Email 电子邮件
Your answer
Parent Permissions 家长许可
Medias *
I hereby consent to the use of any photographs/video tape or any media taken of my child by the school for the purpose of advertising or publicizing events, activities, facilities and programs of the school in newspaper s, newsletters, website, other publications, television, radio and other communications and advertising media.
Student Work *
I authorize the school to publish my student work for the purpose of showcasing and recognizing high achievement and good examples of student learning.
Emergency *
In a medical emergency, the school has my permission to take my child to the emergency room of the nearest hospital when I cannot be contacted, and the hospital staff has my authorization to provide treatment, which a physician deems necessary for the well being of my child.
How you find us *
Check what applies 怎样知道长城中文学校
Required
Disclaimer *
By submit the form, we/our family hereby release, waive, discharge,and forever hold harmless to Great Wall Chinese Academy, its staff, promoters, and sponsors, from any loss or damage,and any claim of damages resulting from our participation in Great Wall Chinese Academy's program on account of any injury to my person, or property, whether caused by negligence or otherwise.
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