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
Name:____________________________________Surname:____________________________
Date and Place of Birth:_______________________________Nationality:______________________
Address:__________________________________________________________________________
Tel:_______________________________________Email:__________________________________
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
MEDICAL INFORMATION
- The following vaccinations are required: TB, Tetanus, Polio, and DT. Please include with your application a copy of a doctor's certificate showing vaccinations.
- Please indicate any chronic diseases (malaria, asthma) which might require special or medical supervision.
- Please note any allergies, medical intolerances, and/or contra-indications.
- 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.
AUTHORIZATION FOR EMERGENCY TREATMENT
(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______________________________
Name:_________________________________________________________
Home address and Tel:__________________________________________________
Work Address and Tel:_____________________________________________
Health Insurance Provider:_______________________________________________________
Policy Number:________________________________________________________
Signature:______________________________ Date:_________________________
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