APPLICATION FOR JAPANESE PROGRAM (2017SUMMER)
AT
MOMOYAMA GAKUIN (ST.ANDREW’S) UNIVERSITY
PERSONAL INFORMAION: (Please type or write very clearly)
NAME:
Last Name / Middle Name / First Name
In Katakana:
Birth Date: Sex: Female [ ] Male [ ]
Year/Month/Day / (Age)
Nationality:
Address:
House or apartment number,street name,etc
City/Town,Province, Country,Postal Code
Phone Number: Fax Number:
E-mail:
University/Major:
Emergency Contact:
Name Relationship Phone Number
FAMILY MEMBERS:
Name Relationship Age Occupation/Study
1)
2)
3)
4)
5)
EDUCATIONAL BACKGROUND:
High School Graduate:[ ] Year of graduation:
University Student: [ ] Year of graduation: or 1st[ ] 2nd[ ] 3rd[ ] 4th[ ]
JAPANESE ABILITY:
On a scale from 0 to 5, how would you judge your Japanese ability? (Please circle)
Speaking & Listening (Almost none at all) 0 1 2 3 4 5 (Very good)
Reading & Writing (Almost none at all) 0 1 2 3 4 5 (Very good)
PERSONAL BACKGROUND:
Smoking:[ ] No[ ] Yes
Social Drinking: [ ] No [ ] Yes
Medical Background:Do you have any particular medical problems,allergies and/or handicaps?
[ ] No [ ] Yes
If yes,please specify:
Special Diet: [ ] No [ ] Yes
If yes, please specify:(Vegetarianetc.)
(*We cannot guarantee that your host family can accommodate a special diet.)
Food Preferences:
I like:
I dislike:
Interests,Hobbies,Favorite Activities and/or Sports:
Activities to watch:
Activities to participate:
TRAVEL EXPERIENCE:
Have you ever traveled outside of your home country? No [ ] Yes [ ]
If yes, please describe where, when and why you went:
SELF-INTRODUCTION:
What should your host family know about you? Please try to describe your personality, character, or habits as accurately as possible. Which adjectives best describe you? How do you see yourself? How do other people see you? It’s a good idea to ask your family members or friends for their opinions. Please be frank and offer as much Information as possible.
TYPE OF HOMESTAY FAMILY I FEEL WOULD BEST SUIT ME:
The following information will be used to assist us in matching you with a host family, but it is important for you to understand that we cannot guarantee that your host family will meet each and every point on this page.
SMOKING:
[ ] Non-smoking family preferred [ ] I am a non-smoker but a smoking family is acceptable
[ ] Smoking family preferred [ ] No preference
PETS:
[ ] No pets of any kind
[ ] No (please specify) [ ] Any pets acceptable
KIDS:
Will you live with younger kids? [ ] Yes [ ] No
HOUSEHOLD RESPONSIBILITIES:
Are you able to cook for yourself, when necessary? [ ] Yes [ ] No
In your opinion, what are the most important qualities and/or characteristics that a host family should possess?
I UNDERSTAND THAT ALL MY PREFERENCES REGARDING A HOMESTAY FAMILY MAY NOT NECESSARILYBE MET. I ACCEPT TO BE A RESPONSIBLE AND ACTIVE MEMBER OF MY HOMESTAY FAMILY'SHOUSEHOLD.
SIGNATURE: DATE:
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