The Future Teaches Chinese
   BANGOR CHINESE SCHOOL
                    
                Teacher Summer Program Registration Form 
                                                            (June 18 –June 29, 2012)

Name: _____________________________________Date of Birth: ___________________________   
If you teach, please tell us which courses:  _______________________________________________ _________________________________________________________________________________
            School or Organization: _____________________________________________________________ 
            City/Town/State of school or organization: ______________________________________________
Home Address: ____________________________________________State: _________Zip: ______   
Home Phone: ___________________________________Work Phone: _______________________
Cell Phone: ______________________ Email: ___________________________________________ 
Emergency Contact Name: ______________________ Phone: _______________________________
Do you want/require college credits?  Yes____ No____  Do you want/require CEUs? Yes____ No___  
Will you wish to be housed in the residence hall during the summer program?  Yes______ No_______
(Note：participants who live in 50 miles away have priority to be housed)

Please summarize you professional goals, i.e. what do you hope to attain by your participation in our summer teacher program” STARTALK: The Future Teaches Chinese”.

I learned of the program from: _______________________________________
   
   I would like to receive information about: 
       2012 Trip to China                      Maine Chinese Language Conference            Other events

Signature: ______________________________________     Date: ___________________

            Please return to:  BANGOR CHINESE SCHOOL, 53 Cumberland Street, Bangor, ME  04401