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Summer Programs

Peer Mentor Application Form Chinese Immersion Summer Day Camps for Ohio Students

June 16 – 27, 2008
The Ohio State University K-12 Chinese Flagship Program

To apply for the Peer Mentor Program, you will need to provide the following:

1. Completed application form (below); and
2. Two reference letters (see the Reference Form below).

We will contact each finalist to schedule an interview. If you have any questions regarding this program, please contact us at the email address listed at the end of this form.

1. Personal Information

Name _______________________________ Date of Birth _______/_______/_______

Place of Birth (City, State, Country) _____________________________________________________________________

Sex: Male ___ Female ___

Home Address _________________________________________________________________

City _____________________ Zip Code _____________ County ___________________

Telephone (home)___________________________ Cell Phone___________________________

E-mail address (Please print clearly) ________________________________________________

Your current grade level at school (only 6-12th graders are eligible): _______________________

Name and address of your school: __________________________________________________

Your immigration status: U.S. citizen ____ Permanent Resident ____ Other ____

2. Language Background

List any foreign language courses you have taken, including Chinese or Chinese Heritage School courses:

What do you consider to be your native language? ____________________________________

What language is spoken most frequently in your home? ________________________________

Have you ever lived or studied in a country other than the U.S.? Yes ___ No ___

If yes, where and for how long? ____________________________________________

3. Experience in teaching/tutoring Chinese language (Begin with current or most recent)

4. If you are not a native speaker of English, provide the following information.

Evaluate your own ability in English according to the scale below. (Circle your response.) (3 = High, 2 = Above average, 1 = Low, X = unknown)

Ability to engage in daily conversation: 3 2 1 X

Ability to communicate in a variety of situations: 3 2 1 X

Ability to read newspapers and magazines: 3 2 1 X

Ability to write effectively: 3 2 1 X

5. If you are not a native speaker of Chinese, provide the following information.

Evaluate your own ability in Chinese according to the scale below. (Circle your response.) (3 = High, 2 = Above average, 1 = Low, X = unknown)

Ability to engage in daily conversation: 3 2 1 X

Ability to communicate in a variety of situations: 3 2 1 X

Ability to read newspapers and magazines: 3 2 1 X

Ability to write effectively: 3 2 1 X

6. Self-Evaluation: Please rate yourself by checking the appropriate box.

7. Statement of Understanding

The OSU K-12 Chinese Flagship Program provides intensive Chinese Immersion Summer Day Camps (in the metro areas of Cleveland, Columbus and Dayton) during June 16--27, 2008 at no cost to students and peer mentors, including food and materials (not including transportation). I understand that the peer mentor requires a commitment of at least four hours a day during the above program period, with an hourly compensation to be determined at the time of interview. I fully understand the nature of this program and will abide by its requirements and guidelines. I also understand that submitting this application does not guarantee my recruitment into the program as a peer mentor.

Signature ________________________________________ Date _____________

Parent/ guardian's signature _________________________________ Date _____________

8. Statement of Affirmation

I affirm that the information I have provided on this application form and any additional information I submit is complete, accurate, and true to the best of my knowledge. 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 as a peer mentor of the Summer Day Camp program.

Student's signature ________________________________________ Date _____________

Parent/ guardian's signature _________________________________ Date _____________

9. Reference Form

Please ask two people to fill out references for you using the form provided below. You should ask individuals who can assess your ability to succeed as a peer mentor in Chinese language and culture (e.g., teachers or employers). Family members may not provide these references.

If you are submitting the letters of reference yourself, make sure the referees sign across the seal of the envelope. Please fill out the top portion of the reference form before giving it to your referees.

Please send your completed application to the appropriate address as follows:

• Cleveland area: Liming Wang (liming36460@yahoo.com), Principal of the Cleveland Contemporary Chinese School, 28950 Naylor Drive, Solon, OH 44139
• Columbus area: Max Xu (xudengke@yahoo.com), past Principal of the Ohio Contemporary Chinese School, P.O. Box 82578, Columbus, OH 43202
• Dayton area: Q. Quinn Li (liq@muohio.edu), Principal of the Greater Dayton Chinese School, 1161 Charter Place, Centerville, OH 45458

Please note that priority will be given to applicants who submit both the Application and Reference Forms on or before April 11, 2008.

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Reference Form for Teacher/Facilitator Applicant Chinese Immersion Summer Day Camps for Ohio Students

June 16 - 27, 2008
The Ohio State University K-12 Chinese Flagship Program

To be Completed by Applicant:

Applicant's Name: ___________________________________________________
Indicate below whether you waive the right to check the references to be provided to you. Check only one of the spaces below.
I waive my right to view this reference. ____

I do not waive my right. ____

Signature____________________________ Date _________________________

To be Completed by Referee:

The above individual is applying to the Chinese Immersion Summer Day Camp as a teacher or facilitator. This is a highly intensive program that will require motivation and skills on the part of the applicant and will require that the applicant teach Chinese language and culture to non-heritage students during June 16-27, 2008. Please consider these requirements as you fill out this reference form.

1. How long have you known the applicant and in what capacity?

2. Please rate the applicant in the following areas according to the scale below.
(3 = High, 2 = Above average, 1 = Low, X = unknown)

Analytical ability: 3 2 1 X

Creativity: 3 2 1 X

Level of commitment: 3 2 1 X

Patience: 3 2 1 X

Discipline: 3 2 1 X

Emotional stability: 3 2 1 X

3. Please comment on the applicant's ability in Chinese and/or English depending on the context in which you know the applicant. Any additional comments that you can provide about the applicant would be greatly appreciated. If you prefer, you may attach an additional sheet with your comments.

Please return this form to the applicant in an envelope with your signature across the seal, or if you prefer, mail or email it to the appropriate address as follows.

Columbus Area:

Mr. Max Xu
Ohio Contemporary Chinese School
P.O. Box 82578
Columbus, OH 43202
E-mail: xudengke@yahoo.com

Cleveland Area:

Mr. Liming Wang
Cleveland Contemporary Chinese School
28950 Naylor Drive
Solon, OH 44139
E-mail: liming36460@yahoo.com

Cincinnati Area:

Mr. Quinn Q. Li
Greater Dayton Chinese School
1161 Charter Place
Centerville, OH 45458
E-mail: liq@muohio.edu

Please note that priority will be given to applicants who submit both the Application and Reference Forms on or before April 11, 2008.

To be completed by referee:

Your Name: _____________________________________ Title: __________________________________________

Affiliation: _____________________________________________________________

Address:___________________________________________ City: _____________ State: _________________________

Zip Code: ________________________________________

Phone: ________________________ E-mail: _________________________________________

Signature: ____________________________________________ Date: _________________________

If you have questions about the mentor application form or reference form of the Chinese Immersion Summer Day Camp, please contact the heritage school coordinator in your area (contact information above), or send an email to StarTalkChinese@osu.edu.

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