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.LANGUAGE CENTERFU JEN UNIVERSIITY輔 仁 大 學語 言 中 心Tel.：886-2-29052414、886-2-29053721886-2-29052487Fax：886-2-29052166e-mail：flcg1013mails.fju.edu.twhttp:/www.lc.fju.edu.tw台北縣新莊市中正路510號510, Chung Cheng RoadHsin Chuang, Taipei CountyTaiwan, R.O.C. 暑期遊學團申請表 APPLICATION FORM FOR SUMMER STUDY TOUR請以正楷或打字填寫下列資料Please print or type the following information:六個月內半身近照兩張Please attach 2 head & shoulder photos(taken within last six months)中文姓名Name in Chinese出生日期Date of Birth (month) (day) (year)外文姓名Name in English(Given Name) (Surname)性別Sex Male Female國 籍Nationality護照號碼Passport No.最高學歷 Highest Educational Attainment畢業日期Date of Graduation學號(For Office Use Only)永久地址Permanent Address電話號碼Telephone No.傳真號碼Fax No.通訊地址Mailing Address電話號碼Telephone No.傳真號碼Fax No.電子郵件信箱E-mail Address手機號碼Cell Phone No.在台地址Address in Taiwan電話號碼Telephone No.手機號碼Cell Phone No.緊急聯絡人 Person to Contact in Case of Emergency居住地In your Country聯絡人姓名Full Name關係Relationship電話號碼Telephone No.電子郵件信箱E-mail Address手機號碼Cell Phone No.在台灣In Taiwan聯絡人姓名Full Name關係Relationship電話號碼Telephone No.電子郵件信箱E-mail Address手機號碼Cell Phone No. 學過華語者，請詳細填寫下列資料：If you have ever leaned Mandarin, please answer the following items in detail: 您學過多久的華語？ How long have you studied Mandarin? 每週_小時，學了_年_個月(_ hours per week, for_ years_ months) 在哪裡學的？Where did you learn it? 在自己國家In my own country:每週_小時，學了_年_個月(_ hours per week, for_ years_ months) 在台灣In Taiwan:每週_小時，學了_年_個月(_ hours per week, for_ years_ months) 在中國大陸In China: 每週_小時，學了_年_個月(_ hours per week, for_ years_ months) 其他 Other _:每週_小時，學了_年_個月(_ hours per week, for_ years_ months)請列出您最近學習的華語教材：Please list the Mandarin textbooks you have studied recently： 填表日期： Date you are completing this form以下為辦公室專用，請勿填寫。(For Office Use Only): 接受申請 否決申請 原因： 收件日期 審核日期 主任簽章： 免簽證 停留簽證(可延長) 來台日期 始業日期 結業日期 天 LANGUAGE CENTER FU JEN CATHOLIC UNIVERSITY 天主教輔仁大學語言中心 HEALTH CERTIFICATE FOR INTERNATIONAL STUDENT個 人 基 本 資 料Basic Data姓 名Name性 別Sex Male Female照 片(加蓋檢查單位印章)Photo stampedofficial stamp護照號碼Passport No.出生日期Birthday血 型Blood Type國 籍Nationality出生地點 Birth Place現在通訊地址Present Mailing Address個 人 病 史Medical History 過去是否患有下列疾病 ： Have you ever had any of the following diseases？( Each item must be answered“No”or“Yes”) 1.心臟病 Heart Disease 2.高血壓 Hypertension 3.肺 病 Lung Disease 4.氣 喘 Asthma 5.肝 病 Liver Disease 6.糖尿病 Diabetes 7.腎臟病 Kidney Disease No Yes No Yes No Yes No Yes No Yes No Yes No Yes8.癲 癇 Epilepsy9.瘧 疾 Malaria10.結核病 Tuberculosis11.登革熱 Dengue Fever12.過 敏 Allergy13.其 他 Others No Yes No Yes No Yes No Yes No Yes_身 體 檢 查Physical Examination1. 身高 Height: _ cms2. 體重 Weight: _ kgs 3. 血壓 Blood Pressure: _/_mm Hg4. 脈搏 Pulse: _ time/min5. 皮膚 Skin: Normal Abnormal6. 視力 Vision: Right _/ Left _7. 耳朵 Ears: Normal Abnormal 8. 眼睛 Eyes: Normal Abnormal 9. 心臟 Heart: Normal Abnormal 10.肺臟 Lungs: Normal Abnormal11.肝臟 Liver: 12.脾臟 Spleen: 13.甲狀腺 Thyroid gland: 14.淋巴腺 Lymph nodes: 15.體肢運動 Locomotors: 16.精神狀態 Mental Condition:若是精神狀態異常，病If abnormal, specify disease:17.其他 Others: Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal Normal Abnormal名是： _ 實 驗 室 檢 查Laboratory Examinations 1.HIV 抗體檢查 Serological Test for HIV: Positive Indeterminate Negativea. Screening Test: EIA Serodia Othersb. Confirmatory Test: Western Blot Othersc. 2.梅毒血清檢查 Serological Test for Syphilis: Positive Negativea. RPR b. VDRL c. TPHA d. Others 3.胸部X光檢查肺結核 Chest X- Ray for Tuberculosis: Normal Abnormal_ 結論：根據以上對_先生/女士/小姐之檢查結果，他/她 是 不是 合格的。 Conclusion: Above is the medical report of Mr./Mrs./Ms_ He/She is is not fit. 意見 Suggestion: 負責醫師簽字 Signature of Physician: _( Valid for Six Months ) Name & Signature 檢查單位蓋章 Official Stamp: _ 日 期 Date: _month day year精选word范本！
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