Home
Home

Archives
Classes

Ex
Exhibitions

Book
Gallery Shop

About
About Us

Links
Calendar

Go to CCC Home


Image Chi-Root

Application Form for
the In Search of Roots Program

 

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:

______________________________________________




Updated: March 14, 1998

Return to Top

 

Chinese Culture Center
750 Kearny Street, 3rd Floor
San Francisco, CA 94108

Ph: 415 / 986-1822
Fax: 415 / 986-2825
E-Mail: info@c-c-c.org