1、1爱在四川，大熊猫爱心体验实践活动申请表Application Form for Intl Students Summer Work & Travel Programs - GPHL时间： 年 月 日Date: 姓 名Name性 别Gender国 籍Nationality住 址 Address 电子邮件 Email 联 系方 式Contact联系电话 Telephone学 号Student ID护 照 号 码Passport Number出 生 年 月Date of Birth对饮食是否有特殊要求 Special requirements on diet:无 None；清真 Halal mea
2、ls；其他（请注明）Others (Please specify) 是否饲养过宠物（特别是猫或狗）？如果有，请问是什么时候？Have you ever raised any pets (especially cats or dogs)? If you have, when?过去是否患有下列疾病：（每项后面请回答“否”或“是” ）Have you ever had any of the following diseases? (Each item must be answered“Yes”or“No”)斑 疹 伤 寒 Typhus fever No Yes 细菌性痢疾 Bacillary dys
3、entery No Yes小儿麻痹症 Poliomyelitis No Yes 布氏杆菌病 Brucellosis No Yes白 喉 Diphtheria No Yes 病毒性肝炎 Viral hepatitis No Yes猩 红 热 Scarlet fever No Yes 产褥期链球菌 Puerperal streptococcus NO Yes回 归 热 Relapsing fever No Yes 感 染 infection No Yes伤寒和副伤寒 Typhoid and paratyphoid fever No Yes流行性脑脊髓膜炎 Epidemic cerebrospina
4、l meningitis No Yes是否患有危及公共秩序和安全的病症：Do you have any diseases or disorders endangering the public order and secure? 您是否购买了人生意外伤害保险？Have you purchased a life accident insurance?本人慎重承诺，所填内容属实，如有不实本人自愿承担一切后果。I seriously commit that all information given above is true. If false, I voluntarily bear all the consequences.本人签字： Signature注：将填好的申请表格提交至留学生办公室 E101（Bring the completed form to the Room E101 of International Students 2Division）
