Application Form for 2017 Shanghai Youth Science Camp

July9-July 15, 2017

Personal Information
Full Name (as shown in passport): / Date of Birth(dd/mm/yyyy): / Nationality:
Gender:
Male
Female / Passport No.:
Date of Expiry (dd/mm/yyyy):
Current Address (including postal code and city): / Phone(including country code):
E-mail:
Name of High School: / Grade: / High School Contact Details:
Dietary Preference: Vegetarian Halal Chicken & Fish Only None
Food Allergies(if there are any):
Emergency Contact
Name of Guardian: / Relationship:
Email: / Phone:
Address (including postal code and city):
Name and Address of Company / Organization: / Job Title:
Statement of Purpose
(Please write in at least200Chinese Characters to explain why do you want to join this program and what would you like to achieve from it?)
By my signature/by submitting this application form, I confirm that I have read and understood the information above and solemnly declare that the information I have provided is correct.
Signature of Applicant: Date:
Signature of Guardian: Date:

Indemnity & Authorization

For Guardian:

I, the undersigned, declare thatI understand that my child participates in the Shanghai Youth Science Camp at his/her own risk.I give permission for my child to attend this program from 9 Jul -15 Jul 2017, and to travel to and from in any transport provided. I guarantee that the information on the Application Form is true to my knowledge.As far as I know he/she is in good health.I agree that Shanghai Youth Science Camp may authorize on my and my child’s behalf whatever medical treatment he/she may require in an emergency situation. I accept responsibility for payment of all expenses associated with such treatment.

I also give permission to Shanghai Youth Science Camp to use the personal information of the guardian and participant for the necessary applications for documents and for communication purposes and to use any videos, photographs, surveys, etc. of/by the participant for promotional purposes of Shanghai Youth Science Camp.

I hereby agree to indemnify and hold blameless the Shanghai Youth Science Camp, its officers, any individual staff, volunteers,all other persons and organizations associated with the program against any and all claimswhatsoever that may arise inconnection with the death, injury, illness of my child or any loss or damage to the propertyof my child duringthe camp or while travelling to and from the camp.

For Applicant:

I, the undersigned, declare thatI am in good health. I guarantee that the information on the Application Form is true to my knowledge. I will obey the regulations and rules set by Shanghai Youth Science Campto be held from 9 Jul -15 Jul 2017, and I will take responsibility for and be very careful of my personal safety and health. I agree to participate in all the activities designated by Shanghai Youth Science Camp.

I give my permission for Shanghai Youth Science Camp to use any videos, photographs, surveys, etc. of/by myself for promotional purposes of Shanghai Youth Science Camp.

I agree to indemnify the Shanghai Youth Science Camp,its officers, any individual staff, volunteers, all other persons and organizations associated with the programagainst all claimswhatsoeverthat may arise inconnection with my death, injury, illness or any loss or damage to my propertyduringthe camp or while travelling to and from the camp.

Signature of guardian: Date:

Signature of participant: Date: