2018 Jr. Ambassador Program to Asahikawa Japan Application Form

2018 Jr. Ambassador Program to Asahikawa Japan Application Form

Bloomington/Normal-Asahikawa Japan Sister Cities

Please fill out the application below, print out, sign, date and send in with first deposit by March 2, 2018

【Student Information】
Student’s Full Name (Last, First and Middle): Click here to enter text.
Date of Birth (MM/DD/YYYY): Click here to enter text. / Insert photo
Home Address: Click here to enter text.
Home Phone Number: Click here to enter text. Student’s cell phone number: Click here to enter text.
Student’sEmail: Click here to enter text.
Current School: Click here to enter text. Current Grade: Click here to enter text.
【Teacher Reference】Name of Teacher: Click here to enter text.
Teacher Email: Click here to enter text.
【Passport Information】 Do you have a current passport?
***If you answered “Yes”, please attach the picture page of your passport with this application***
Passport Number: Click here to enter text. Expiration Date: Click here to enter text.
【Health Status---please list all conditions】Click here to enter text.
If you’d prefer to talk to the program chair in person, please contact Toyoka Nishihara @ 309-830-5905
Medications taken regularly: Click here to enter text.
Allergies (list all medicine): Click here to enter text.
Primary Physician’s name: Click here to enter text. Phone number: Click here to enter text.
【What food do you like and dislike?】
Click here to enter text.
Would you be willing to try new foods?
【Are you allergic to anything including food, pets, etc. ---Please list all information that is important】
Click here to enter text.
【Family Information】
Father’s Name: Click here to enter text. Mother’s Name: Click here to enter text.
Address---If different from student address
Click here to enter text.
Father’s Cell Phone: Click here to enter text. Mother’s Cell Phone: Click here to enter text.
Father’s Email address: Click here to enter text. Mother’s Email: Click here to enter text.
Father’s occupation and place of employment:
Click here to enter text.
Mother’s occupation and place of employment:
Click here to enter text.
【Sibling Information】List name and age
Sibling #1: Click here to enter text. Sibling #2: Click here to enter text.
Sibling #3: Click here to enter text. Sibling #4: Click here to enter text.
【Student Travel Experience】
Have you previously participated in any foreign travel?
When, Where and length of stay: Click here to enter text.
Have you ever traveled alone without another family member?
When, Where and length of stay: Click here to enter text.

What activities do you like to do with your family?

Click here to enter text.

What are your hobbies and interests?

Click here to enter text.

What subjects do you like/dislike in school and why?

Click here to enter text.

What activities are you involved at school/and our outside of school?

Click here to enter text.

Please write two or three paragraphs about the reason for applying to the Jr. Ambassador program to Asahikawa, Japan.
Click here to enter text.

Student Signature:______Date:______

For Parent(s) of the Applicant

My Signature indicates:

1. that I have read this application, the agreement andagree to all the terms therein; and give consent to sign the minor child travel form before departure.

2. that my child must attend 80% of the preparatory classes as developed and made available by the Sister Cities Committee;

3. that I authorize and release my child’s teachers and counselors to discuss my child’s performance and behavior with the committee and acknowledge that the same will be confidential between the teacher/counselor and the committee;

4. that, if the Exchange Program has less than 5 participants, it may be canceled by the Sister Cities Committee, in which case all money will be refunded;

5. that I agree to send my child on the Exchange Program, to reside with a family/families chosen by the Sister Cities Committee, in Asahikawa, Japan.

6. that, any expenses (including medical and unforeseen travel) that occur while traveling will be the responsibility of the parents.

7. that, once selected all travel arrangements and communication with the travel airlines, buses, etc. will be done by Sister Cities Members only.

8. that, I will enroll my child in Traveler’s insurance offered by the designated travel agent. Level of coverage will be the parent’s responsibility to choose.

Parent’s or Guardian’s Signature______Date: ______

======Tear off and save ======

Please enclose a $1,000.00 deposit with application.

(Check payable to: Bloomington – Normal Sister Cities Committee)

Mail to :Toyoka Nishihara

1813 Loblolly Drive

Normal, IL 61761

Payment Schedule:

March 2, 2018Application and first payment of $1,000.00 due

April 8, 2018Second payment of $1,000.00 due

April 29, 2018Balance due (at anytime before said date)

Questions?Toyoka Nishihara @309-830-5905 or