Application Form (For University Students and Non-Student Adults)

Pilgrimage to Hiroshima 2017

Application Form (for university students and non-student adults)

1．Full Namein both Alphabet and Chinese characters if any： /

2．Gender： We need this information for room allocations.

3．Exact age as of the program dates： For purchase of travel insurance.

4．Name of your YWCA/School name/Grade/Place of work：

5．Your Contact Address(To which you wish to receive materials on the program.)

Address：

TEL： FAX：

E-mail：

6．Emergency Contact during the program

Full Name： Relation to you：

Address：

TEL： FAX：

7．Any medical concernsand/or special needs that our staff need to know?

8．Dates of participation

2nights (August 9～August 11）

Living in Hiroshima and do not need accommodation during the program

with optional tour 3nights (August 9～August 12）

＊Put X in a box of the tour you want to join

□ Miyajima, World Heritage Site

□ U.S. Base in Iwakuni

10． Field Trip (for details of each course, please refer to the program description)

Course1:Touring the City CentrearoundHiroshima Castle

Course 2: Hiroshima, Told by Junior High and High School Students

Course 3: Walk in Hiroshima of “The Summer Flower” by Tamiki Hara

Course 4: Journey of Korean Victims and Survivors

First choice: Second: Third:

11. Would you like to have a guided tour in Peace Memorial Museum?
(We may be unable to meet your request as the program is on the peak season)：

12. Any requests regarding accommodation? (Please indicate if you wish to share a room with your company)

13. Have you participated in the Pilgrimage to Hiroshima before? If so, how many times?

□I have participated ( ) times, in the year ( )

□ This is my first time

14．Language level

Mother language：

Japanese (Fluent / Good / Fair / Poor)

English (Fluent / Good / Fair / Poor)

Would you like to receive language assistance?：

*Chinese and Korean interpretations will be available.

*Support to other languages can be available if circumstances allow.

15．

*1Photos and videos taken in the program will be only used for the purpose of an activity report or public relations introducing this program.

*2 Participants aged under 18 years old need to have a consent of their parent or other guardian as a guarantor.

Note:

For those who wish to apply from outside Japan, only applications from YWCA members will be accepted. Please apply through your National YWCA, with a letter of recommendation from your YWCA.

Your personal information is only used for the purpose of ‘Pilgrimage to Hiroshima’ administration and YWCA of Japan.

＜Application & Inquiry＞

YWCA of Japan（Attn:Makuya/ Usui）

E-mail：

YWCA of Japan

1-8-11-302 Kanda Surugadai, Chiyoda-ku, Tokyo 101-0062, JAPAN

Tel:81+(0)3-3292-6121 Fax:81+(0)3-3292-6122