the In Search of Roots Program
English Name: ___________________________
Chinese Name: ___________________________
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.
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: