APPLICATION FORM / ISI Japanese Language Education Center
9F 2-29-14 Minami Ikebukuro, Toshima-ku, Tokyo, 171-0022
TEL：03-5960-1335 FAX：03-5960-1336
E-mail: URL:
School you are applying□ Takadanobaba campus
□ Ikebukuro campus
□ Kyoto campus
□ Nagano campus / Office use
Please make sure to fill out this form by yourself. We place your family by this application form and also this form goes to your host family directly.
Name / Picture indispensable!
Gender / M ・ F / Blood Type
Birthday (yy/mm/dd) / Age
Nationality / Religion
Occupation / Major
Home Address
Telephone / E-mail
Emergency Contact / Passport No.
Name and relation
Mother Tongue / English Level
Japanese Level (Please state your Japanese level for each section)
1.Beginner 2. Intermediate 3.Advanced 4.Higher advanced
Speaking: 1 2 3 4 / Listening: 1 2 3 4 / Reading: 1 2 3 4 / Writing: 1 2 3 4
Are you smoker? / YES NO / Are you Vegetarian? / YES NO / Do you like pets? / YES NO
Do you like kids? / YES NO / Do you drink? / YES NO
Do you mind if other international students stay in the same Homestay? / YES (I mind) No (I don’t mind)
Please list any foods you dislike or cannot eat: / Please list any foodsyou like very much:
Do you have any allergies?
Do you have any illness that we should know about?
Do you have any physical disabilities?
Other important information about your health
Flight Schedule
Indispensable! / Arrival Date / year month date time
／ ／ ／ ：
Flight No.
Leaving Date / ／ ／ ／ ：
Flight No.
Home-Stay Arrival Date / ／ ／ ／ ：
Home-Stay Leaving Date / ／ ／ ／ ：
Do you need Airport Pick up? / NO ･ One Way ・ Both Way
Self Introduction
Please write things you want to do in Japan, requirements for your host family, etc.
Terms and Conditions1. / Students will be arranged in single placements.
2. / A single room with desk will be provided. Washroom facilities including bath/shower will be shared with the host family.
3. / Bed or futon will be provided for the student.
4. / 2 meals (breakfast and dinner) will be provided 7 days a week.
5. / Instead of taking meals included in the plan, in case eating out for those meals with people outside of family, the expenses will be paid by students.
6. / Students will be responsible for paying any of their personal phone charges, cleaning bills, purchases of everyday items and goods.
7. / Including offering meals at home, the host family will be responsible for paying electricity and hydro charges.
8. / Homestay areas will be usually located within 1 hour of the school via public transportation, but they could be farther during the high season of July and August.
9. / Host families may in some cases be of other nationalities.
10. / The needs of the students (in regards to conditions such as allergies, smoking, etc.) will be taken into consideration when placing them with their host families.
11. / English language ability will not be considered as criteria in the selection of homestay families (the main language will be Japanese).
1. / I understand that Homestay is not a hotel service. I am prepared to be treated as any other member of the host family and respect all rules, advices and judgments. I will ensure I clearly understand the rules of the homestay through discussion in the initial stages of my stay.
2. / I will make every effort to interact with the family members. I will communicate to my host parents any foods that I can not or prefer not to eat. I will also make an effort to try different foods.
3. / I will try not to be excessive in the use of electricity, water, gas etc. If there is any differences of opinion on this, I will discuss this with the family.
4. / I am willing to accept any reasonable household rules that my host family sees fit to impose for my welfare. I understand that I will contribute to the household duties as other family members do. I will abide by the homestay rules in regards to keeping my room tidy, washing dishes, laundry etc.
5. / I will respect the property and privacy of my host family's personal belongings and affairs. I acknowledge and agree that I will be liable for any loss or damage I deliberately cause to my host family's property.
6. / I will inform my host family of my whereabouts and plans each day. I will be punctual for meals and be home by the decided acceptable time of return. I will contact my host family if I am going to be late. I will seek permission well in advance from my host family if I want to invite friends over.
7. / I am aware that I should offer to pay for myself if my host family takes me out (meal, movie, zoo etc.) or away (e.g. overnight or weekend trip). If I feel that the cost and/or frequency of outgoing are excessive, I am aware that I can decline the host family's invitation.
8. / I will abide by Japanese law at all times, and be aware that laws and penalties may differ from my own country.
9. / I acknowledge that during the Homestay period my person and my property will be at my own risk and will not hold the host family liable for any personal injuries or losses of property caused by any act or omission of the host family.
10. / I must comply with all of the rules and regulations of this program, or I will be returned home immediately under my financial responsibility.
11. / I follow the «refund policy» in case of cancelling this program or changing schedule after the initial application.
I have read and understood all terms and conditions and I agree to be bound by them.
Applicant’s signature:
Parents’ signature(if student is under 20):
Date:
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