Print out part II, have any of your subject teachers or any foreign language teacher to fill it out, put it in a sealed envelope and send it to Aldeen Foundation *
Send school transcript in sealed envelope mail it to Aldeen Foundation *
Please fill out all parts of the application, and do not forget to click on submit.
Remember to have your parent's signature before submitting it.
For any Question? Call (626) 557-2199
Or e-mail Lina Kholaki: Aldeenstartalk09@aldeenfoundation.org
*Aldeen Foundation
651 N. Orange Grove Blvd. Suite A
Pasadena, CA 91103
This program sponsored by STARTALK and Aldeenfoundation 2011
Part 1: Aldeen Student APPLICATION Form 2011
Last Name
First Name
Grade by Fall 10-11
Current School
Home Address
City
State
Zip Code
Question 1
Have you had any instruction in Arabic? When and where?
Daily Weekend Summer Camp After School
Question 2
Are you a heritage speaker of Arabic (You have at least one family member who speaks/ spoke Arabic at home, but was predominately educated in English)? If yes, please continue. If no, skip to question 10.
Question 3
If you were born outside of the US, where were you born and at what age did you enter the US?
Question 4
What dialect do you speak at home?
Question 5
Have you travelled to Middle East? Which country?
Question 6
How long did you stay?
Question 7
Do you have an extended family member who live with you? Yes or No If yes:
Do you communicate with them in Arabic?
always sometimes usually never
Question 8
How much Arabic is spoken at home?
10%-20% 30%-50% 70%-100%
Question 9
Do you communicate electronically (e-mail, chat, texts) with native speakers of Arabic?
yes No sometimes always
BELOW IN EACH QUESTION Please rate your own proficiency in Arabic, on a scale from 0-5 with 0 being no proficiency and 5 being an educated native speaker of Arabic.
Question 10
Listening Comprehension:
0 1 2 3 4 5
Question 11
Speaking
0 12 3 4 5
Question 12
Reading:
0 12 3 4 5
Question 13
Writing:
0 12 3 4 5
Father's Name
Mother's Name
Parents Email
Student's Home Address
City
State
Zip
Father's Work Address
City
State
Zip
Mother's Work Address
City
State
Zip
Program obligation: In accepting this free of charge program, the student is expected to:
Attend all classes from July 5th-July 22nd ,2011 (except weekend)
9:00am-3:00pm
Participate in language daily assignments.
Participate in Startalk pre &post program survey.
Actively participate in class activities and activities throughout the day
All costs are covered, also brunch meal will be served.
Parents Signature
Student Signature
Home Phone
Mother's Work Phone
Father's Work Phone
Father's Work Phone
Father's Cell Phone
Name
Relationship
Cell Phone
Work Phone
Home Phone
Name of Doctor
Phone
Name of Hospital
Phone
Insurance carrier
Policy #
Allergies
Medication Needed
Please list any medical or emotional conditions that the program administrators and staff should be aware of concerning your child. This information will be kept confidential.
Medical Authorization
In the event of illness or accident of my child, any administrator or member of the teaching staff of the Arabic Language program, in whose care my child is entrusted, is authorized to administer basic first aid for relief. If the staff is unable to reach us if further medical care is needed, consent is hereby given to the staff to transport my child to any hospital and to consent to treatment and hospital care to be rendered to the child under the general or special supervision and upon the advice of a licensed physician and surgeon. I further agree to relieve the Arabic Language program and the staff from any liability because of the exercise of this consent.
Photograph Consent
On behalf of the student, I hereby consent to the use of photographs, video footage, class work, and quotations of the Student in publications, website, and other media related to the immersion program.
Please initial here if you do not consent
Consent Form
We, the undersigned parent/guardian and student have read the Aldeenstartalk 2011 "Arabic 4 All" Summer Immersion Course in Modern Arabic for High school students' information and Parent hereby given permission for Student to participate in the Aldeenstartalk 2011 Program indicated in this application. In consideration of the Student being accepted as a participant in the Program, we release, hold harmless and indemnify Aldeenfoundation, its officers, directors, agents, employees, partners, sponsors and affiliates from and for any claim, injury or other liability of any kind which is caused directly or indirectly by Student, or which results from or during Student's participation in the Program. Further Aldeenfoundation liability for any and all injuries or losses related to or arising from Student's participation in the Program. We understand that Student may be included in photographs and videos that may be taken during the Program including any testimonials and hereby consent thereto and the use thereof by Aldeenstartalk for all lawful purposes, without compensation. A comprehensive Code of Conduct, which details guidelines for behavior during the Program and prohibits possession of such substances as drugs, alcohol, and tobacco, will be included in the Student's Acceptance Packet. We understand that this form and other required forms must be signed and returned prior to and as a condition of participation in the Program. We further understand that failure to abide by this Code of Conduct may result in Student's immediate dismissal, return home at own expense, and forfeiture of all tuition paid. We understand that applications from qualified students are processed in the order received and that enrollment may exceed available spaces. We understand that this is an application for Student's participation in the Program and enrollment is contingent upon approval by Aldeenfoundation, in its sole discretion. We understand that stipend will be awarded to students who fulfill the program requirement, make all the assignment and receive C as a grade or above. We understand and agree to the terms of the Aldeenfoundation program policy for stipend as outlined above.
I AGREE Yes
Parent/Guardian Signature
Date
Disclaimer
I understand that some of the activities and workshops of this program will be videotaped and I might appear in such videos. Any videos in which I appear will be used for the purpose of assessment and evaluation and for educational purposes only and will not be used for any other purposes without my explicit written consent.
WAIT!!! BEFORE YOU SUBMIT APPLICATION TO US MAKE SURE THAT ALL FIELDS ARE FILLED IN, TO AVOID DELAY IN PROCESSING YOUR APPLICATION. THANK YOU!
