 Application Form
for
English Name: ___________________________ Chinese Name: ___________________________ Address: _______________________________ CITY: _________________________________ STATE: ___________________ZIP:__________ Home Phone: (______)_____________________ Work Phone: (______)_____________________ Date of Birth: _____________ For Student: Grade/Year in School ____________ NAME OF SCHOOL OR EMPLOYER: _______________________________________ Father's English Name: ______________________ Father's Chinese Name: ______________________ Father's Ancestral Village: ________________________________________ Mother's English Name: ______________________ Mother's Chinese Name: ______________________ Mother's Ancestral Village: ________________________________________ Do you intend to make the journey to China? _______ I understand that acceptance in this program will require me to attend regular seminar sessions, do outside research, create an exhibit on my research, and present my experience to other groups. SIGNATURE: ________________________________ DATE: ____________________ If you are under 18 years of age, please also ask father/mother/guardian to sign below. I give permission for ____________________________________ to participate in the In Search of Roots program. SIGNATURE OF PARENT/GUARDIAN: ______________________________________________
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Chinese Culture Center
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