Summer Programs East Asian Concentration (SPEAC)

2014Workshop in Beginning Chinese

Department of East Asian Languages and Literatures

National East Asian Language Resource Center

East Asian Studies Center

The Ohio State University

Application Form

I. Personal Information

1). Name Date of Birth

Last Nam First Name Middle Name Month / Date / Year

2). Last 4 digits of U.S. Social Security Number ______Sex: Male Female

3). Current Mailing Address

City ______State (Prefecture, Province, etc.) ______

Zip (Postal) Code Country

4). Telephone (home) Cell Phone

5). E-mail address

6). What do you consider to be your native language? English Other (specify)

7). What is your ethnic background? (OPTIONAL: check one) Black, non-Hispanic American Indian or Alaskan native Asian or Pacific Islander Hispanic White, non-Hispanic

8). Emergency Contact (name)

Relationship (mother, etc.) _ Phone

II. Educational background(List all post-secondary institutions attended, beginning with current or most recent)

Institution (Name) / Address
(City, Country) / Dates Attended
From (Mo/Yr)
To (Mo/Yr) / Major or Program / Degree / Date Received (Mo/Yr)

III. Language background

Please list the languages you have studied other than your native language. Indicate (circle) your approximate level of competency: (1- poor, 2-fair, 3-good, 4-excellent)

Language / Speaking / Listening / Reading / Writing
1 2 3 4 / 1 2 3 4 / 1 2 3 4 / 1 2 3 4
1 2 3 4 / 1 2 3 4 / 1 2 3 4 / 1 2 3 4
1 2 3 4 / 1 2 3 4 / 1 2 3 4 / 1 2 3 4
1 2 3 4 / 1 2 3 4 / 1 2 3 4 / 1 2 3 4

IV. Statement of Intention and Signatures

The SPEAC Workshop in Beginning Chinese is a non-residential, non-credit workshop. It requires participants to be in a 55-minute sessionevery day, Monday through Friday (except national holidays), and to spend about two hours daily,studying in preparation for the sessions. The Workshop does not provide any academic credit. Participantsare required to obtain the course materials and responsible for their cost. Participants are not required to pay any instructional fees.

Participant’s failure to abide by these provisions may result in his/her dismissal from the Workshop.

I fully understand the nature of SPEAC Workshop in Beginning Chinese and will abide by the requirements and guidelines of the program.

Signature: Date

I affirm that the information I have provided on this application form and any additional information I submit related to the admissions is complete, accurate, and true to the best of my knowledge. If applicable, I authorize each high school and each college or school I have attended to release academic and personal information, as well as my employer to verify my dates of employment. I agree that as a participant in the OSU Workshop, I will be subject to The Ohio State University Code of Student Conduct. I understand that furnishing false or incomplete information on any part of this application material or other related materials may result in cancellation of admission to the Workshop.

Signature: Date

V. Consent to be video Recorded

As part of a university committed to teaching excellence, the Department of East Asian Languages and Literatures (DEALL)continually works toward improving the teaching qualities of its language instructors. As part of this endeavor, our language programs are integrated with the graduate-level teacher training courses we offer.We will be videotaping many of the classes to help us discuss the teaching and learning. Video clips and photographs are also used on our promotional materials, including, but not limited to DEALL web site and Facebook site and flyers.

We ask that you take a few moments to review the consent below and sign below to indicate your consent.

By signing my name, I agree to be video recorded and photographed in my classes during the summer of 2014, with the understanding that the recording will be used by the faculty and staff of DEALL or the Ohio State University exclusively for the training of teachers or graduate teaching associates in Japanese and Chinese, or for research in East Asian language pedagogy. I also understand that short video clips and photographs may be used by DEALL to promote its programs and student accomplishments. It is my understanding that DEALL or the OSU will not use the recordings or photographs in any known ways that would disadvantage me. I will not claim any rights for the recorded material.

Name Program: Workshop in Beginning Chinese

Signature: Date