Student Information Form | The Chinese Language Institute

If you would like to apply for one of CLI's programs in Mainland China (Guilin Immersion Program, Study Abroad, and Teach in China), please visit studycli.org/apply.

Basic Information

Name

First

Middle

Last

Enter your full name as it appears (or will appear) on your passport. Include your full middle name (if any), not just your middle initial. CLI relies on this when making a variety of bookings on your behalf.

Date of Birth

Program Selection

Sex

Female
Male

Email

Phone Number

Emergency Contact Information

Name

First

Last

Relationship

Email

Country or region of residence

Cell Phone Number

Work Phone Number

Dietary & Medical Information

To ensure the health and safety of every CLI traveler, it is important that we collect the following information, which we will have access to throughout your travels with us. Please note that sharing this information is optional and, if provided, will remain confidential and only accessible by program leaders and personnel directly associated with your upcoming program.

I wish to share dietary restrictions and/or medical information with my program staff and administrators.

Yes
No

Section 1: Dietary Information

Food Allergies

If none, leave blank

Additional Dietary Comments

Please use the above space to provide any additional information about your dietary needs and preferences that you think might be helpful to your program organizers.

Section 2: Medical Information

Current Prescription Medications

If none, leave blank

Drug Allergies

If none, leave blank

Medical Conditions (including Mental Health)

If none, leave blank

Name of Primary Care Physician

If none, leave blank

Phone Number of Primary Care Physician

If none, leave blank

Email of Primary Care Physician

If none, leave blank

Additional Medical Comments

If none, leave blank

Section 3: Pre-existing Medical Conditions

Please answer Yes/No to the following. In the past 3 years, have you experienced:

Joint Injuries

Yes
No

Circulatory problems

Yes
No

High blood pressure or heart disease

Yes
No

Anxiety disorder

Yes
No

Clinical depression

Yes
No

Muscular injuries

Yes
No

Seizures

Yes
No

Asthma

Yes
No

Broken bones

Yes
No

Migraines

Yes
No

Additional Comments

Participant Signature

I declare that:

I have read and I accept CLI's Terms and Conditions (link opens in new tab).
My information as entered above is accurate and correct to the best of my knowledge.
I agree to abide by the laws of my program’s host country or territory throughout the duration of my CLI program.

I declare that:

I have read and I accept CLI's Terms and Conditions (link opens in new tab).
My information as entered above is accurate and correct to the best of my knowledge.
I agree to abide by the laws of my program’s host country or territory throughout the duration of my CLI program.
I authorize CLI to share the above self-reported medical and health information with my upcoming study abroad program's faculty leader, relevant administrators, and necessary destination-country personnel.