Document: A

*Please fill in this form on PC, and send by e-mail. (The form written by hand writing cannot be accepted.)

平成２２年度第５回日欧高校生交流プログラム（Data Form）

Japan-Europe High School Student Exchange Program for 2010

Country:

Name of the Embassy / Consulate General you apply:

Write in Japanese or English

* Write exactly as it is written in your passport

Please attach a copy of your passport

※印は在外公館が記入 (※should be filled in by the Embassy / Consulate General.)

From A to G, please send the data to the officer. Regarding H, please follow the instruction on page 4.

A. Basic information

1. Your information

First name*: / Middle name*: / Surname*:
※（カナ表記） / ※（カナ表記） / ※（カナ表記）
Sex: M F / Nationality: / Nick name: / Photo data
Passport No. : / expiration date ( yyyy / month/ dd ): /
Date of birth ( 19yy / month/ dd ): 19 / / Age:
Email: / Tel:
Address:
Zip code: Country:
Your area of residence: Urban Suburban Small town Rural area
Airport you wish to use on departure:
①
② / ※（カナ表記） ①
②
2. Family information
Who do you live with? :
Father Mother Stepfather Stepmother Guardian Other ( )
Who is your custodial parent? :
Father Mother Stepfather Stepmother Guardian Other ( )
Father (or male guardian)
name : age:
address(if different from yours):
Occupation : Employer :
Business Telephone number :
Mother (or female guardian)
name : age:
address(if different from yours):
Occupation : Employer :
Business Telephone number :
Brother’s name(s) and age(s): ( , )
Sister’s name(s) and age(s): ( , )

3. Emergency contact

(For in case we were not able to contact your parents.)

name :
address :
Phone number(Home) :
(Work) :
Relationship :

B. Additional Information

1. Information which affects your stay in Japan.

Do you have physical restrictions, impairments, or allergies that will limit placement options or your participation in school activities? / Yes No
If yes, please describe:
Do you have any pet? / Yes No
If yes, what kind? :
Do you have problem if there is any pet in the place where you will stay? / Yes No
If yes, what kind? :
If yes for the question above, is that still a problem for you to have the pet outside of the house? / Yes No
Are you a vegetarian? / Yes No
If you have problem with foods, please check. / Fish meatPoultry
Dairy productsOthers( )
Do you have any dietary restrictions？ / Yes No
If yes, what kind? :
The reason? (Medical, religious, etc…) :

2. Religion

Your religious affiliation
How often do you attend the services? / Weekly Monthly Occasionally Never
In Japan, do you want to attend the service? / Required Not necessary

3. Smoking

（In Japan, it is prohibited by law for persons under 20 years of age to smoke.）

Are you a smoker? / Yes No
Do you have problem if there are smokers in your host family? / Yes No
If yes for the question above, is that still a problem for you if the smokers smoke outside of the house? / Yes No

4. Bicycle

Do you have any problem riding on a bike to go to school? / Yes No

C. Self Introduction

Please describe yourself below, especially focusing on your personality. Also please refer to the things and activities that you are interested in and want to try in Japan. (Please write as much as you can.)

D. Languages

Your mother tongue
Japanese
Score of the Japanese language proficiency test
(If you ever took the test): / How long did you study? :
How did you study? :
Other languages:
1)
Speaking ability:
PoorFair Good Excellent / How long did you study? :
How did you study? :
2)
Speaking ability:
PoorFair Good Excellent / How long did you study? :
How did you study? :
3)
Speaking ability:
PoorFair Good Excellent / How long did you study? :
How did you study? :
4)
Speaking ability:
PoorFair Good Excellent / How long did you study? :
How did you study? :

E. Subject

What kind of subject you are interested in most and why?

What is your future plan? What kind of career you are interested in?

F.Introduction to your host family

To help introducing yourself to a host family, please make a small album with photographs that includes you, your family and friends. Place the photo data below, with a short phrase to describe the photo.

(Minimum 2-3 photos are required.)

G. Letter

For your host family, please write a letter in Englishreferring what you expect from them, by typing or printing legibly in black ink on any kind of paper and hand it in (Minimum 100 words to maximum A4, 1 page.). Please make it sure to type your name at the end of the letter. (Please hand in differently with the other documents.)

H. Signature

1. Please type your name and your parents’ name at the part and print out this page.

2. Sign below and hand it in at the interview.

===== STATEMENT OF AGREEMENT =====

I hereby confirm that the information on the document A is all true. I also understand that a member of host families may be of any race, and believe in any religion, and I accept the conditions of the host family placed under this program.

Student name:

Yes (Please check if you can agree with the statement written above.)

Date

Parent’s name:

Yes (Please check if parents can agree with the statement written above.)

Date

*Please kindly check if there is any part not filled in.

※This section should be filled in by the Embassy / Consulate General.

※在大使館／総領事館（担当官名：）

記入期日： 20 年 月日

短期／長期の希望： 第一希望

第二希望

（第二希望が無い場合は記載なし。）

※大使館員所見

1. 応募者の言語能力につき、評価を行ってください。

1)日本語
話す能力:
挨拶程度挨拶・自己紹介ができる
少々の会話 日常会話問題なし / 聴く能力：
挨拶程度挨拶・自己紹介ができる
少々の会話 日常会話問題なし
2) 英語
話す能力:
挨拶程度挨拶・自己紹介ができる
少々の会話 日常会話問題なし / 聴く能力：
挨拶程度挨拶・自己紹介ができる
少々の会話 日常会話問題なし

２.その他

※全ての箇所が記入されているか、もう一度お確かめ下さい。

1