This is the application form for Summer School. Please copy it into your word processing program and print it out. Send all application materials to Cecile Remington 1034 N. Edgewood St. #1 Arlington, VA 22201 (703) 527-3294 by May 1.

Collège Cévenol Summer School
Application Form


Date and Place of Birth:_______________________________Nationality:______________________



Current Grade and School:____________________________________________________________

School Address and Tel:______________________________________________________________

How many years have you been studying French?___________________________________________

Level of French comprehension:_____Poor_____Average_____Good_____Fluent

Level of French speaking:_____Poor_____Average_____Good_____Fluent


  1. The following vaccinations are required: TB, Tetanus, Polio, and DT. Please include with your application a copy of a doctor's certificate showing vaccinations.
  2. Please indicate any chronic diseases (malaria, asthma) which might require special or medical supervision.
  3. Please note any allergies, medical intolerances, and/or contra-indications.
  4. Include special treatments to be indicated by medical order to the school nurse (spectacles, special treatments, surgery, etc.) A medical certificate is required for exemption form sports.

(to be signed by father, mother or legal guardian of applicant)

I authorize the Administration of Collège Cévenol to take any decision in case of emergency for hospitalization or surgery of my son/daughter______________________________
Home address and Tel:__________________________________________________
Work Address and Tel:_____________________________________________
Health Insurance Provider:_______________________________________________________
Policy Number:________________________________________________________
Signature:______________________________ Date:_________________________

Since 29 Oct 2000