ISI Japanese Language School Education Center
9F 2-29-14 Minami Ikebukuro, Toshima-ku, Tokyo, 171-0022 Japan TEL : +81-3-5960-1335 FAX : +81-3-5960-1336
E-mail: URL:
Note: All sections on this form must be completed. Please type/print clearly and check boxes where appropriate.
I would like to apply forthe Summer Course2018 (Kyoto Campus).
APPLICANT’S INFORMATIONFamily Name
As shown on your passport: / First Name
As shown on your passport: /
Family Name in
Chinesecharacters if any / First Name in
Chinesecharacters if any
Full Address: / Tel:
Line ID:
E-mail: / Date of Birth: / YYYY/ MM/ DD/
Sex: / ☐ Male ☐ Female / Nationality:
Size: (for Yukata-Premium & Standard courses only) / Please write your height. / Please write your shoes size.
Passport No.: / Valid Until: / YYYY/ MM/ DD/
Occupation: / Company or school name: / Mother tongue
Emergency Contact: / Name: / Tel: / Relationship: / Country:
JAPANESE ABILITY
Have you studied Japanese before? / ☐ / Yes (How long? Year Months) / ☐ / No
---If YES,
where did you learn Japanese? / ☐ Japanese Language School ☐ University/High School ☐ Self-study
☐ Private Tutor ☐ Others
---If YES,
which textbook(s) have you used? / Have you taken the Japanese Language Proficiency Test (JLPT)? / If yes, ( Level)
COURSE*
Courses / July / ☐Premium ☐Standard ☐ Basic
August / ☐Premium ☐Standard ☐ Basic
ACCOMMODATION & AIRPORT PICK-UP
Do you need accommodation arrangement? / ☐ / Yes / ☐ / No
---If YES, where do you want to stay? / ☐ Homestay ☐Student House (☐ single ☐ twin)
---If YES, Move-in (Check-in) date: YYYY/ MM/ DD/ / Move-out (Check-out) date: YYYY/ MM/ DD/
Airport for arrival / ☐ Kansai International (KIX) ☐ Itami (ITM)
Flight number (if you have already booked): / Date of arrival: YYYY/ MM/ DD/
Do you need airport pick-up? *Please note that pick-up service is only available for the arrival and departure times stated below.
Destination / Arrival / Departure / By / Fare
☐ / Homestay / 08:00-18:00 / 10:00-18:00 / Public transportation with staff orshared taxi / JPY 18,000
☐ / Student House / 08:00-18:00 / - / From JPY 6,000
VISITS TO JAPAN
Have you ever been denied entry into Japan? / ☐ / Yes (Reason: ) / ☐ / No
*This course is only available for those with beginner to lower-intermediate(aprox. N4)level. Please, note that you won’t be able to transfer to the Academic Japanese Course.
I hereby declare that I understand the information above and that the provided information is true and correct.
Applicant’s signature: / Date: / YYYY/ MM/ DD/We kindly ask you to fill in the following questions regarding allergies and food habits.
Attention: If you have any allergies or special food habits we ask you to please be careful. We would appreciate it if you could understand that, unfortunately, it is not possible for us to keep track of all the students’ diets. We apologize for the inconveniences this may cause.
Q1：I have a food allergy
☐ Yes⇒ Please check all that applies ☐No ⇒ Go to 2nd question
Food Group☐ Eggs / ☐chicken egg ☐ fish egg ☐Caviar ☐others（ ）
☐Dairy Products / ☐milk ☐ butter ☐ cheese ☐dairy cream
☐any food that contains dairy product ☐others（ ）
☐Grains / ☐wheat ☐soba ☐others（ ）
☐Nuts & Beans / ☐soy beans ☐peanuts ☐almond ☐walnuts ☐others（ ）
☐Crustacean & Shellfish / ☐shrimp ☐crab ☐calamari ☐shellfish( ) ☐others（ ）
☐Fish / ☐fish in general ☐bluefish ☐river fish ☐others（ ）
☐Meat / ☐beef ☐pork ☐chicken ☐canard (duck) ☐ lamb ☐others（ ）
☐Fruits / ☐peach ☐apple ☐banana ☐kiwi ☐mango ☐others（ ）
☐Others / ※Please write specific foods that you are allergic to.
☐Symptoms Level and Details / ☐mild symptoms
☐severe symptoms, cannot eat due to medical recommendation
☐extract or essences are acceptable
☐others（ ）
Q2：I am a vegetarian
☐ Yes⇒ Please check all that applies ☐No ⇒ Go to 3rd question
✔ / Type / Type explanation☐ / ①Semi vegetarian / No meat as much as possible
☐ / ②White meat vegetarian / No meat but only chicken is OK.
☐ / ③Non meat eater / No meat but fish is OK（ inc. Macrobiotic.）
☐ / ④Pesco vegetarian（pescetarian） / No meat, No eggs, No dairy products but fish, crustacean & shellfish are OK
☐ / ⑤Lacto-ovo-vegetarian / No meat, No fish. Egg and dairy products are OK.
☐ / ⑥Vegan / No meat
No fish, crustacean and shellfish
No egg
No dairy products
No zooidal meal
(ex: any extract or essence, lard, gelatin,
honey, dried bonito fish ［flake］, sardine、stock)
☐ / Fruitarian / Eat only nuts（fruit・nuts・vegetable of the tree）
☐ / Others
Q3：I have religious food habits.
☐Yes⇒ Please check all that applies ☐ No ⇒ Go to 4th question
✔ / Type / Type explanation☐ / ①Hinduism / NO beef. For some people, pork is also avoided.
Boiled fish, chicken, lamb, seafood, rice, fruits are used, but no alcohol is used when cooking.
☐ / ②Islam, Muslim religion / NO pork. Four legged beasts, shellfish, calamari, octopus are avoided. Chicken, rice, vegetables, fish will be used. No alcohol will be used when cooking.
☐ / ③Jewish religion / The food will be prepared according to KOSHER regulations. Vegetables and fruits are all OK.
Beasts with hoof can be eaten, beef, lamb, goat, deer, are possible.
Pork is prohibited. As white meat, chicken, domestic duck, goose turkey, dove are possible,
Underwater fish are possible.
Fish with scales and fillet are possible. Eel, catfish, conger eel are forbidden.
Shrimp, crab and other crustaceans, calamari, octopus, shellfish are forbidden altogether.
As for the others, the cooking utensils for dairy products and meat will be different, thus food will be prepared according to KOSHER regulations.
Q4：If you have any other information about your allergies and food habits, please write down the details.
Declaration on Health Status
Please use this declaration form to provide information regarding your current health status.
To lead healthy lives for all students, it is important for faculty members to be aware of your health condition. Please fill in the following sections in detail. Please acknowledge that we do not provide medical practice or dispense medication at school. This declaration will be kept confidential.
- How is your current health condition? Please select from the following options.
- Are you currently undergoing treatment for any health issues?
☐ Yes / From Year Month
Name of disease（ ）
- Are you currently taking any prescribed medications? Did you take any prescribed medications in the past one year?
☐ Yes / Time of prescription Year Month
Medicine： Tranquilizer ・ Antiepileptic drug・
Asthma medications ・ Others（ ）
- Have you had any surgeries or were hospitalized in the past five years?
☐ Yes / Time in hospital Year Month
Reason（ ）
- Do you have a past history of diseases
※if so, please select from the following option, and fill out the checked sections in detail.
（1）Tuberculosis infection / ☐ No
☐ Yes / Onset
Year Month / Current status
☐ Recovered ☐ Taking medicine
（2）Mental disorder / ☐ No
☐ Yes / Onset
Year Month / ☐ Depression ・ ☐ Anxiety ・ ☐ Panic disorder
☐ Attention deficit disorder（ADD) ・
☐ Attention deficit hyperactivity disorder （ADHD)
☐ Other（ ）
（3）Allergies
including asthma / ☐ No
☐ Yes / Onset
Year Month / ☐ Food ・ ☐ Medicine ・ ☐ Chemical products
☐ Other（ ）
（4）Malaria, or other
infectious diseases / ☐ No
☐ Yes / Onset
Year Month / Name：
（5）Diabetes / ☐ No
☐ Yes / Onset
Year Month
（6）Other / ☐ No
☐ Yes / Onset
Year Month / Current Status
☐ Recovered ☐ Taking medicine
- Do you have any vaccination history?
- Special needs for dietary treatment or diet restriction
Reason（ ）
- Please write any other information regarding your health condition that the school should know in advance.
I hereby verify that the information above is true and correct.
Signature: ______
Date: 年Year 月Month 日Day