Short term Application form



I would like to apply for the Summer Course 2019 (Tokyo-Takadanobaba Campus /Kyoto Campus/).APPLICANT’S INFORMATIONFamily NameFirst Name(s)1206511430Photograph*Please send your portrait photo by data.00Photograph*Please send your portrait photo by data.Family Name in Chinese characters (if any):First Name(s) in Chinese characters (if any):Address:Tel:Line ID:E-mail:Date of Birth:　　　　YYYY/MM/DDSex:? Male ? FemaleNationality:Yukata Kimono(Tokyo: All Students)(Kyoto: Premium Course Only)　*We’ve prepared the following sizes. Please let us know if you need a different size.Men:Height:166cm~175cm (5’4~5’8 ft)Shoe Size: 26cm (US:8, EU:42)Women：Height:155cm~170cm (5’1~5’6)Shoe Size 23~24.5cm (US:5~6 1/2, EU:36-39)Do you need a different size?Height: 　　　　　　　　　　　cm/ ftShoe Size: cm / EU size / US sizePassport Number:Valid Until: YYYY/ MM/ DD/ Occupation:Company/School Name:Native Language:Emergency Contact:Name:Tel:Relationship:JAPANESE ABILITYHave you studied Japanese before?? Yes (How long? Years Months) ? NoHave you passed the JLPT?? Yes (JLPT N ) ? NoCOURSELocation? Tokyo (Takadanobaba)? KyotoCourse? Premium ? General? JLPT Specialized Intensive Course (Tokyo-Takadanobaba Only) ? 　?　N2 Preparation class ? N3 Preparation classFor Only Kyoto Campus Students *We would like to know which tour you’re interested in. Please number the tour options below from 1 to 5, with 1 being your first choice etc. Unfortunately we cannot guarentee you’ll be placed in one of your top choices.Group Tour( 　)　Manga & Cinema　（　　）History & World Heritage　 （　　）Fashion　　 ( ) Nature & Parks　　 （　　）Amazing KyotoACCOMMODATIONDo you want us to provide accommodation?? Yes ? No--- If YES, where do you want to stay? *Tokyo Campus students can choose only Homestay.? Homestay　 ?　ISI Provided Accommodation/Kyoto Campus only　(Twin) 　　--- If No, where will you stay? Place: ? Hotel　 ?　Friend’s House ?　Other ( )Address:Check-in: YYYY/MM/DD Check-out: 　YYYY/MM/DD Arrival Airport:?　Narita（NRT）　?　Haneda（HND） ?　Kansai（KIX）　?　Itami（ITM）Flight number (if you have already booked):Flight Arrival Date: YYYY/MM/DDWould you like Airport Pick-up? ＊Only for the dates and times listed below-1481124-3175? No ? One-way (Pick One→)? Round Trip (Homestay Only)00? No ? One-way (Pick One→)? Round Trip (Homestay Only)? DestinationArrival TimeDeparture TimeByOne-way Fare?ISI Arranged Accommodation (Kyoto Campus Only) 10:00-15:00-Meeting staff or Public transportation with staff or shared taxi.6,000 JPY ~ 31,000 JPY?Homestay08:00-18:0010:00-18:00PAST VISITS TO JAPANHave you ever been denied entry into Japan??No ?Yes (Reason: 　　　　　　　　　　　　　　　　　　　　　　　　　　　)* The Tokyo Summer Course is only available for students with up to N4 Japanese level and The Kyoto Summer Course is only available for students with beginner to lower-intermediate (approx. N4) Japanese. You can't transfer to the school's Academic Japanese Course during the Summer Course.*I have confirmed the refund policy.I hereby declare that I understand the information above and that the provided information is true and correct.Applicant’s Signature:　　　　　　　　　　　　　　　　　　　　　　　 　　　　　　 Date: 　　　　　 　 /Year 　　/Month 　 　/DateThank you for applying to ISI’s Summer Course. We may provide food to participants at times during the course, so we would like to know if you have any allergies or dietary restrictions. We would appreciate it if you could understand that, unfortunately, it is not possible for us to keep track of all the students’ diets, so students must take care when eating. Question 1：Do you have a food allergy? ?No ?　Question 2　　　　　　　?Yes ?　　Please tick all that apply. Food GroupDetails? Eggs? Chicken Eggs　? Fish Eggs/Caviar　 ? Other（　　　　　　　　　　　　　 　）? Dairy? Milk　　? Butter　? Cheese　? Dairy Cream　? Anything that contains dairy ? Other（　　 　　　　　　　 　）? Grains? Wheat　? Soba　 ? Other（　　　　　　　　　　　　　　　　　　　　 ）? Nuts and Beans? Soy Beans　? Peanuts　? Almonds　? Walnuts ? Other (　　　　　　　　　　　　　　　　　　　　 　）? Crustacean and Shellfish? Shrimp　? Crab　? Squid/Calamari　? Shellfish（ ） ? Other（　　　　　　　　　　　　　　　 　　　　 　 ）? Fish? Fish in General　? Bluefish　? River Fish ? Other ( 　　　　　　　　　　　　　　　　　　　　）? Meat? Beef　? Pork　? Chicken　? Duck　? Lamb ? Other（　　　　　　　　 　　　　　　　　　　　　　　　　　）? Fruit? Peach　? Apple　? Banana　? Kiwi　? Mango ? Other（　　　　　　　　 　　　　　　　　　　　　　　　）? OtherEnter here: ( )Allergy Symptom Details? Mild symptoms? Severe symptoms, doctor recommends against it? Extract or essences are acceptable　　? Other（　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　）Question 2：Are you vegetarian? ? No ?　Question 3 　? Yes ?　Please tick all that apply.TypeDetails?Semi-VegetarianNo meat whenever possible?White Meat VegetarianNo meat except chicken?Non-Meat EaterNo meat but fish is okay (including macrobiotic).?Pesco Vegetarian (pescetarian)No meat, eggs or dairy products, but fish, crustacean and shellfish are okay.?Lacto-Ovo VegetarianNo meat or fish, but eggs and dairy products are okay.?VeganNo meat, fish, crustacean, shellfish, eggs, dairy products, or anything that originates from animals. (ex: any extract or essence, lard, gelatine,honey, dried bonito flakes, sardine, chicken stock etc)?FruitarianOnly food that comes from trees (fruits, nuts, tree-born vegetables etc)?Other(　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　)Question 3: Do you have any religious dietary restrictions?? Yes ?　Please tick all that apply　　　? No ?　Question 4ReligionDetails?HinduismNo beef. No pork for some people either.Boiled fish, chicken, lamb, seafood, rice, and fruit are okay, but no alcohol is used when cooking.?Islam/MuslimNo pork. Four legged animals, shellfish, squid/calamari, and octopus are avoided. Chicken, rice, vegetables and fish are okay. No alcohol will be used when cooking.?JudaismFood must be prepared according to Kosher regulations.Meat made from animals with hooves, such as beef, goat, deer, and lamb, is okay. White meat such as chicken, domestic duck, goose, turkey and pigeon is okay.Filleted fish with scales are okay. However, pork, eel, catfish, conger eel, shrimp, crab and other crustaceans, calamari, octopus, and shellfish can’t be eaten.Cooking utensils for dairy products and meat must be different.Question 4: If you have any other information you’d like to add about your diet, please write it in the box below.　　　　　　　Health DeclarationPlease tell us about any health problems you have. It is important for staff and faculty members to be aware of your health condition. Please fill in the following sections in detail. Please be aware that the school cannot give medical advice or dispense medicine. All information will be kept confidential.How is your current health overall? 　Please select from the following options. 　? Very Good ? Normal ? Not Good　　? BadAre you currently undergoing treatment for any health issues?? No? YesFrom　　　　　　Year 　　　　Month　　　Condition（　　　　　　　　　　　 　　　　　　 　）Are you taking any prescribed medications? Have you been prescribed medication in the past year?? No? YesPrescription Date　　　 　　　Year　　　 　Month　　Medicine:　Tranquilizer　?　Antiepileptic drug?Asthma medications　Other (　　 　 　　　 　）Have you been hospitalised or undergone surgery in the past 5 years?? No? YesTime in hospital　　　　　 Year　　 Month　　Reason (　　　　　　　　　　　 　　　　　　　　　　　 　　）Do you have a history of the following conditions, or any chronic illnesses??　No ?　Yes※ If YES, please fill in the following section in detail.Tuberculosis? No? YesSymptoms Onset　　　　　Year　　　　　MonthCurrent Condition?　Recovered　　　　　?　Taking MedicationMental Health Disorder? No? YesSymptoms Onset　　　　　Year　　　Month? Depression ? Anxiety ? Panic Attacks ? Attention Deficit Disorder（ADD)? Attention Deficit Hyperactivity Disorder (ADHD) ? Other ( )Allergies(including Asthma)? No? YesSymptoms Onset　　　　　Year　　　Month? Food ? Medicine ? Chemical Products　? Other（　　　　　　　　　　 　　　　 ）Malaria, or other infectious diseases? No? YesSymptoms Onset　　　　　Year　　　　　MonthDisease Name:Diabetes? No? YesSymptoms Onset　　　　　Year　　　MonthOther? No? YesSymptoms Onset　　　　　Year　　　MonthCurrent Condition?　Recovered　　　　　?　Taking MedicationWhat have you been vaccinated against?? BCG ? M.M.R. ? Polio ? Measles ? Rubella ? Diphtheria　? Tetanus ? Meningitis ? Other（　　　　　　　　　 ）Do you have any special dietary needs?? No ? YesFrom　　　　　Year　　　　MonthReason: (　　　　　　　　　　　　　　　　　　　 ）Please write any other information the school should know in advance.I hereby verify that the information above is true and correct.Signature:　　　　　　　　　　　　　　　　　　　　　　　　 　　 　　 　　　　　　　　　Date: 　　　　　 　　/Year　 　　 　　/Month 　　　 /Date ................
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